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International Journal of Transgenderism

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70 U.S. Veterans with Gender Identity Disturbances: A Descriptive Study

Everett McDuffie & George R. Brown
a b a b

East Tennessee State University, Johnson City, Tennessee Mountain Home VAMC and East Tennessee State University, Johnson City, Tennessee

Available online: 13 May 2010

To cite this article: Everett McDuffie & George R. Brown (2010): 70 U.S. Veterans with Gender Identity Disturbances: A Descriptive Study, International Journal of Transgenderism, 12:1, 21-30 To link to this article: http://dx.doi.org/10.1080/15532731003688962

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International Journal of Transgenderism, 12:2130, 2010 ISSN: 1553-2739 print / 1434-4599 online DOI: 10.1080/15532731003688962

70 U.S. Veterans with Gender Identity Disturbances: A Descriptive Study

Everett McDufe George R. Brown

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ABSTRACT. This study describes the largest population of veterans referred for a gender identity disorder (GID) evaluation. Most were self-referred, others were referred by their commanding ofcer. A search of the English language literature revealed no similar studies on veterans other than a pilot project by the second author. Methods: Retrospective descriptive data were obtained from chart reviews of 70 U.S. veterans who were evaluated by the second author for gender disturbances over a 20-year period (1987 to 2007). The modal veteran with gender identity disturbance was a natal male (91%) identifying as female, >40 years old, Caucasian, employed, with more than 12 years of education. Fifty-seven percent were parents with a history of sexual involvement with opposite sex individuals. Histories of autogynephilia were not elicited in vets interviewed since 1997. Classic ight into hypermasculinity was described by a majority of the natal male vets as a retrospective understanding of why they joined the military. Psychiatric comorbidities (43%) included post traumatic stress disorder (PTSD), depression, schizophrenia (N = 1), substance use disorders (17%), dissociative identity disorder (N = 1), and personality disorders (11%). Ninety-three percent met criteria for diagnosis of GID or GID not otherwise specied; suicidal ideation was reported by 61% with one or more suicide attempts by 11% of 56 responding; and 4% reported genital self-harm. Although 11% expressed active thoughts of surgical self-treatment, most expressed a desire for physician-performed sex reassignment surgery (SRS). Cross-dressing behaviors were common, and currently reported arousal with cross-dressing was reported by 13%, 63% of whom were not diagnosed with GID. Conclusion: Veterans often reported that they joined the military in an attempt to purge their transgender feelings, believing the military environment would make men of them. Most were discharged before completing a 20-year career. More than half received health care at veterans affairs medical centers, often due to medical or psychiatric disabilities incurred during service. Comorbid Axis I diagnoses were common, as were suicidal thoughts and behaviors. KEYWORDS. Transsexual, military, veteran, gender identity

This article is not subject to U.S. copyright law. Everett McDufe, MD, is a clinical Assistant Professor of Psychiatry at East Tennessee State University in Johnson City, Tennessee. George R. Brown, MD, is Chief of Psychiatry at Mountain Home VAMC and Professor of Psychiatry at East Tennessee State University in Johnson City, Tennessee. The views expressed in this paper are those of the authors and do not necessarily reect those of the United States government or the Department of Veterans Affairs. The authors have no potential conicts of interest to report with respect to this work. Address correspondence to George R. Brown, 549 Miller Hollow Road, Bluff City, TN 37618. E-mail: George.brown@va.gov
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People who experience a signicant degree of nonconformity between their anatomic sex and their felt gender are referred to as transgendered persons (Bolin, 1998; Brown, 2001). This is not a diagnostic term, it is a descriptive term. Only a subset of transgendered persons, possibly a minority, would meet DSM-IV-TR criteria (American Psychiatric Association, 2000) for a diagnosis of either gender identity disorder (GID) or gender identity disorder not otherwise specied (GIDNOS). It has long been known that transgendered persons have served their countries in the armed forces (Brown, 1988). Reports of transgendered women serving as male conscripts or as medics in the American Civil War are well substantiated (Gansler, 2005). However, little has been published on transgendered persons who serve in the modern armed forces and who report to a psychiatrist for evaluation. Brown (1988) reported on a small number of veterans and active duty service members who were evaluated and/or treated for GID. A comprehensive literature search on the topic of transgendered military personnel and veterans completed by Whitten (2007) revealed no additional peer-reviewed papers on this subject in the ensuing 20 years. As Whitten (2007) points out in her review, the 2002 U.S. Army Medical Services Standards of Medical Fitness states in Section 230: Psychosexual conditions that the causes for rejection for appointment, enlistment, and induction are transsexualism, exhibitionism, transvestitism, voyeurism, and other paraphilias. An update of this regulation 5 years later seems to have no signicant clinical change or recognition that transsexualism is a gender disorder, in that disqualifying conditions for candidates for enlistment/commissioning (under U.S. Army Medical Services Standards of Medical Fitness [2007], Section 227, Learning, Psychiatric and Behavioral Disorders) state that current or history of psychosexual conditions, including, but not limited to transsexualism, exhibitionism, transvestism, voyeurism, and other paraphilias, are disqualifying. Those who attempt to enlist are subject to a comprehensive physical exam and screening for mental disorders. Those who report that they are transgendered, whether or not they have had somatic

treatments such as cross-sex hormones or genital surgeries, are rejected as unt by all branches of the U.S. military. Enlistees who attempt to conceal anatomic modications that are inconsistent with their sex of assignment at birth may be denied enlistment if discovered prior to taking their oath. If transgender status is detected after completion of enlistment or commissioning, the active duty member may be discharged under a variety of regulations depending on the individual circumstances (Alexander, Greer, & Westcott, 2007; U.S. Air Force Administrative Separation of Airmen Instructions, 2004; U.S. Air Force Patient Administration Functions Instructions, 2006; U.S. Army Enlistment Regulations, 2002; U.S. Army Active Duty Enlisted Administrative Separations, 2005; U. S. Army Patient Administration, 2008; U. S. Army Medical Services Standards of Medical Fitness, 2002, 2007; U.S. Marine Corps Separation and Retirement Manual, 2001). The potential routes utilized by commanders to effect involuntary discharge of transgendered recruits from service may involve fraudulent enlistment, administrative discharges for homosexuality, cross-dressing (perversion), personality disorders, or criminal conduct outlined in the Uniform Code of Military Justice. Further complicating the issues for transgendered persons in uniform is the fact that any conversations they have with mental health care providers are not privileged or condential, and those providers (including psychiatrists) are obligated to report transgender behavior to the commander of their patient even if the service member came voluntarily to a mental health clinic for help. If active duty service members choose to obtain mental health care from civilian sources, they are obligated to report that they are receiving care outside of the militarys health care system. Failure to report the receipt of care from civilian sources could result in signicant penalties, prosecution, and possibly court martial, depending on the circumstances (Whitten, 2007). While much of the above applies to potential recruits who are aware of their transgender identities and choose to serve nonetheless, a different situation pertains to those who are suffering from gender dysphoria and who

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are actively suppressing, or unconsciously repressing, transgender feelings and/or identications. These recruits have been previously described as taking a ight into hypermasculinity (Brown, 1988), wherein they are attempting to purge any vestiges of transgender thoughts or feelings by immersing themselves in an environment that is strictly dichotomous and intolerant of any blurring of gender boundaries. Transgendered or transsexual natal males can attempt to purge the desire to become feminine by enlisting in an organization that rewards and cultivates exaggerated masculine behaviors: high-risk taking, stoicism, controlled violence, heterosexuality, athletic prowess, and contempt for physical/emotional weakness. Some report they are consciously aware of this at the time of enlistment (suppression), while others report that they only made sense of this dynamic for themselves long after the fact (repression) and that they were not making any attempt to falsify documents or deceive the military recruiters. The importance of lack of self acceptance as a transgendered person, usually accompanied by some degree of self-loathing was noted in the rst study as well (Brown, 1988). Engaging in hypermasculine behaviors is not unique to transgendered natal males who join the military services. This dynamic is apparent in some nonmilitary persons with GID who choose to engage in high risk, macho behaviors such as motorcycle racing, police/security work, re ghting duties, and contact sports. The incidence and prevalence of GID among veterans is unknown. It is likely that the prevalence of male-to-female (MtF) GID among veterans may be higher than the prevalence among nonveterans in the United States based on the ight into hypermasculinity that many MtF transsexuals commonly describe from their late teens. This hypothesis (Brown, 1988) presumes that any cohort of veterans, especially those derived from the last 35 years when the draft was suspended in favor of an all-volunteer force, is enriched by the dynamic described above. This article expands the limited knowledge of Americans who have served in an active duty military capacity and who were evaluated at some time in their lives (during or after military service) for transgender feelings or behaviors.

METHODS
The second author (George R. Brown), trained in the evaluation and management of persons with clinically signicant transgender issues, including GID, evaluated 70 active duty service members or veterans with a primary presenting concern of transgender identity disturbance of some type. Some were evaluated while they were on active duty status in the various branches of the armed forces of the United States and while the evaluator (Brown) was on active duty status himself. The remainder were evaluated in a private practice setting or in a Veterans Affairs medical center. Nearly all were self-referred for evaluation, although several were commander-referred while on active duty status. Evaluations consisted of an extended semistructured clinical interview that averaged 3 hr per patient. The following information was elicited from the evaluees: demographic information, employment history, sexual history, cross-gender behavior history, genital self-harm history, medical and medication information, and use of cross-sex hormones and surgeries. Ten years after the rst paper on autogynephilia was published (Blanchard, 1989), additional questions were added to the sexual and gender history to ascertain whether or not evaluees experienced this phenomenon. At the 20-year mark, application was made to, and approved by, the East Tennessee State University/Mountain Home Veterans Affairs Medical Center Institutional Review Board to conduct a retrospective chart review of these 70 charts and associated videotaped interview segments that were part of the records for some of the evaluees. Some charts had missing data, usually due to nonresponse, for one or more of the descriptive variables studied, therefore the number of subjects for some of the results is less than 70.

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RESULTS
Eighteen of the 70 veterans were evaluated between 1987 and 1997; 52 were evaluated between 1998 and 2007. Age at the time of evaluation was between 29 and 77, with the average age being 48 (SD 9.7 years), median age 49, and

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modal age 46. All subjects had entered active duty service between 1945 and 1990. Natal sex was identied as 64 males (2 of these were found to be intersexed; one with vestigial ovaries, the other with ambiguous genitalia of both sexes; both were raised as males and served as pilots), 1 person of unknown sex, and 5 females. The veteran identied as unknown also failed to choose a subjective gender identity. Physical examinations were not performed on the majority to verify these self-reports (records of physical exam results were usually available) with the exception of those with ambiguous genitalia and those who reported genital self-surgery. Self-reported gender identity was as follows: 55 natal males (with 2 intersexed, raised as males) identied their gender as female; 5 natal males identied their gender as male (none of these were diagnosed with GID); 4 natal males identied themselves as transgender or both male and female; 4 natal females self-identied as male; 1 natal female self-identied as transgender; 1 veteran self-identied as unknown gender when given the options of male, female, transgender, or unknown. Table 1 summarizes the remaining demographic information collected. Table 2 illustrates manifestations of GID from this population. Sixty-four percent (N = 45) were actively cross-dressing; most of these cross-dressed during their consultation, including two while on active duty service. 36% (N = 25) were not cross-dressing or only crossdressed in nonpublic venues. Of the individuals not cross-dressing, some were in the early stages of transition. Individuals from both the active and inactive cross-dressing categories cited concerns about their appearance and passability while cross-dressing in public. Among the 9 veterans citing sexual arousal with crossdressing, 5 of these were not diagnosed with GID or GIDNOS. The remaining 4 veterans with GID/GIDNOS described sexual arousal with cross-dressing in nonfethishistic terms. For example, they appeared to have repressed their sexuality prior to transition, citing disgust of their male genitals and not viewing themselves as sexy. After transition, they indicated they felt congruent with their gender identity, more at ease with themselves, and that sexual desire

and arousal developed thereafter. They specifically did not describe autogynephilia. Further, of these 4 individuals, 2 had already undergone sex reassignment surgery (SRS). Genital self-harm and/or fantasizing about surgical self-treatment (autocastration and/or autopenectomy in an attempt to treat gender dysphoria; Baltieri & de Andrade, 2005; Brown, 2007, 2010/this issue) occurs more frequently among individuals diagnosed with GID than in the general population (De Gascun, Lucey, Kelly, Salter, & OShea, 2006). Three (4.3%) of the 70 veterans studied had actively harmed their genitals. Of the 3 natal males attempting to remove their own genitals, one completed autocastration, one completed autocastration and partial penectomy, and one retained the original genitalia with signicant testicular trauma. An additional 8 veterans revealed serious thoughts about removing their own genitals. Of these 8, 7 were natal males and 1 was a natal female. Many individuals with GID endorse symptoms of depression associated with not being able to resolve or adapt to their condition. Suicidal thoughts typically parallel depressive symptoms. Sixty-one percent (34 of 56) revealed a history of serious suicidal thoughts. The mental status exams reected active suicidal thoughts for only one veteran, which were chronic and not imminent. Eleven percent (6 of 56) revealed a history of potentially lethal suicide attempts. Thirty-nine percent (22 of 56) denied any previous history of suicidal thoughts. Hormone use to achieve feminization or masculinization was prevalent: 77% (50 of 65) were using or had used hormones; 23% (15 of 65) denied ever using hormones. Of the veterans who had used hormones, several revealed that they had acquired the medication illicitly. Postoperative veterans with GID indicated that they were sometimes able to receive cross-sex hormones from Department of Veterans Affairs (VAMC) health care providers. In the cases of illicit use of hormones by natal males with GID, feminizing physical results were evident. More than 50% of the veterans with GID who had never used hormones expressed a strong desire to use prescribed cross-sex hormones. Thirty-four percent (22 of 65) of the veterans evaluated had already

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TABLE 1. Demographic and Clinical Information

Natal male = 64 (91%) Married = 21 (32%) Parents of children = 39 (57%) Caucasian = 60 (86%) Less than 12 years = 3 (4%) Employed = 41 (65%) 29 = 2 (3%) Natal female = 6 (9%) Divorced = 33 (50%) No children = 27 (40%) Asian = 1 (1%) High School equivalent = 8 (11%) Unemployed = 19 (30%) 3039 = 10 (14%)

Sex (N = 70) Marital status (N = 66) Parenting (N = 68) Ethnicity (N = 70) Education (N = 70) Employment (N = 63)+ Age (N = 70)++

Never married = 12 (18%) Adopted children = 2 (3%) Not disclosed = 9 (13%) College and beyond = 46 (66%) Retired/Disabled = 3 (5%) 4049 = 28 (40%) 5059 = 21 6069 = 6 Over 70 = 3 (30%) (9%) (4%) USMC = 5 USCG = 1 USMM = 1 (8%) (1%) (1%)

Utilizing VA care (N = 70) Service branch (N = 67)+++ GID Co-morbidity (N = 65)

Tobacco (N = 68)++++ Suicidality (N = 56)

Psychiatric medication (N = 53)

Using VA = 37 (53%) Not using VA = 33 (47%) Army = 31 (47%) USAF = 18 (27%) Navy = 11 (17%) Axis OneGID/GIDNOS alone = 37 (57%) Additional Axis One diagnoses exclusive of GID/GIDNOS = 28 (43%) Current smoker = 22 (32%) Non-smoker = 46 (68%) History of suicidal ideation = 34 (61%) Denied history of suicidal Past suicide attempt = 6 (11%) ideation = 22 (39%) No psychiatric medications = 28 (53%) Currently prescribed psychiatric medications = 25 (47%)

4 veterans chose not to reveal marital status; category includes being widowed. 5% revealed past heterosexual intimacy. 2 veterans chose not to reveal any parenting role. 9 veterans chose not to disclose ethnicity. 13 veterans (19%) did not disclose highest education level. + 7 veterans did not disclose their employment status. ++ Youngest was 29; oldest was 77. +++ Service branch was not specied in 3 records by which status as veteran was conrmed. USMM (U.S. Merchant Marine) members are VA eligible after serving during wartime. USAF stands for U.S. Air Force; USMC stands for U.S. Marine Corps; USCG stands for U.S. Coast Guard. ++++ 2 veterans did not disclose tobacco use history. Data on suicidal thoughts was missing in 14 records. 17 records did not list currently prescribed medications.

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TABLE 2. Manifestations of Gender Identity Disorder/Gender Dysphoria

Cross-dressing (N = 70) Active cross-dressing = Not cross-dressing = 25 45 (64%) (36%) Sexual arousal with 5 not diagnosed with GID 4 manifested atypical cross-dressing or GIDNOS patterns of sexual (N = 70) arousal with cross-dressing Taken hormones = 50 Hormone use (N = 65) Never taken hormones = (77%) 15 (23%) SRS completed: = 22 Actively requesting SRS Sex reassignment (34%) = 11 (17%) surgery (N = 65) GID diagnosis (N = 70) GID: 60 (86%) GIDNOS = 5 (7%) Not diagnosed with GID or GIDNOS = 5 (7%) Genital mutilation Mutilated genitals = 3 Endorsed thoughts of (N = 70) (4%) genital mutilation = 8 (11%) Gender identity (N = 70) MtF = 55 (79%) FtM = 5 (7%) Transgender = 5 (7%)

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Males not endorsing an alternate gender = 5 (7%)

All 4 diagnosed with GID or GIDNOS; 2 had already undergone SRS. 5 records did not reveal hormone status; illicit use of feminizing hormones was prevalent, and results of use were evident. Among the individuals nave to hormone therapy most desired initiation of treatment. All post-operative veterans were satised with their decision for treatment. More than 50% of the veterans evaluated and diagnosed with GID or GIDNOS desired SRS. 5 veterans were excluded because they were not diagnosed with GID or GIDNOS. 4 natal males and 1 natal female preferred to be identied as transgender rather than the opposite of their natal sex. Despite the impasse of not describing a traditional expression of gender for research purposes, each of these veterans sought anatomical sex reassignment to the opposite of their natal sex. 5 males not diagnosed with GID or GIDNOS identied themselves as their natal sex.

undergone SRS; 17% (11 of 65) of this population was actively seeking SRS and most of the population expressed a desire for eventual SRS. Of the 22 who had completed SRS, all expressed satisfaction with their choice to complete the procedure. None expressed regrets or a desire to reverse the surgery. Of the 70 records reviewed, 60 were diagnosed with GID, 5 with GIDNOS, and 5 were not diagnosed with either condition. Seventy-nine percent (N = 55) identied themselves as natal males who desired being female. Seven percent (N = 5) identied themselves as natal females who desired being male. Another 7% (N = 5) insisted on not being conned to portraying their gender as male or female; this group sought to be recognized as transgender. Nevertheless, each of these 5 veterans desired SRS and cross-sex hormone treatments in order to achieve an anatomical reassignment to the opposite natal sex consistent with the objectives of the other individuals with GID in this study. Five males not diagnosed with GID or GIDNOS identied themselves as male.

Descriptions of sexuality varied widely. Ten MtFs were attracted to males, 20 were attracted to females, 7 were bisexual, and 15 described themselves as asexual. One MtF individual was attracted to transgendered and female partners; another MtF was attracted only to transgendered partners. Of the 5 males not diagnosed with GID, 3 were heterosexual with a history of cross-dressing and the remaining 2 were homosexual men who wanted to appear more female for their male partners. Fiftyseven percent of the natal males reported sexual relations with natal women. Of the 5 veterans identifying their sex as transgender, 3 desired female partners, 1 desired male and female partners, and 1 reported being asexual. Of the 6 FtMs, 3 desired women and 3 described themselves as asexual. Signicant uidity of sexual orientation was not reported by any subjects. For example, those who were exclusively attracted to females remained attracted to females irrespective of the stage of transition and whether or not they had received somatic

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treatments for GID. The only possible exception to this was for the two subjects who reported sexual attraction to other transgendered persons that may not have been a specic orientation earlier in life. Medical and psychiatric comorbidities are described in Tables 1, 3, and 4. Thirty-two percent (22 of 68) were smokers at the time, 47% (25 of 53) were taking prescribed psychotropic medications, 43% (28 of 65) had additional psychiatric diagnoses exclusive of GID, and 57% (37 of 65) had been diagnosed with GID or GIDNOS as their only Axis I diagnosis. Depression, PTSD, and substance use disorders (as a group) were the primary comorbid psychiatric diagnoses. A clear distinction between the symptoms of major depressive disorder and depressive symptoms associated with gender dysphoria/GID was attempted, but there was likely signicant overlap. Veterans not diagnosed with GID or GIDNOS were excluded in order to compare comorbidities among the population with GID/GIDNOS. Some had more than 2 diagnoses on Axis I, and these distinctions are not reected in the table. For descriptive purposes, if a condition was assigned in the record, it was tabulated into a compilation list of Axis I conditions. Among the 5 individuals not diagnosed with GID, 1 was diagnosed with an occupational problem, 1 with transvestic fetishism, and 1 with major depressive disorder. Axis I conditions are listed in Table 3. Many of these veterans served in combat and developed combat-related PTSD. If a veteran had a history of substance abuse other than nicotine dependence, the condition was included. Active substance abuse disorders were assigned if the problematic behavior was present over the 12 months preceding the consultation. Most of these individuals were described as not diagnosed or deferred with respect to Axis II based on the limitations of a single session assessment. Of the 7 veterans diagnosed with a personality disorder, the diagnosis was made only after a long-term assessment or extended psychotherapeutic treatment. Of these 7 veterans, 3 were also diagnosed with GID, whereas the remaining 4 were not. Medical conditions listed under Axis III are noted in Table 4. As is the case in Table 3, one individual may have 2 or more conditions noted. Older veterans

TABLE 3. Incidences of Axis I Comorbidity in Veterans Diagnosed with GID (N = 65)

Depression PTSD Bipolar disorder Schizophrenia Alcohol abuse History of alcohol abuse Alcohol dependence History of alcohol dependence Cocaine abuse History of Cannabis dependence Cannabis abuse Polysubstance dependence Opioid dependence History of opioid dependence History of sedative dependence Other substance abuse Social phobia Panic disorder Dissociative identity disorder 13 9 1 1 1 3 1 3 1 1 2 1 1 1 1 6 1 1 1

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Note. 28% of the veterans diagnosed with GID or GIDNOS manifested other Axis I conditions. Five cases were excluded because they were not diagnosed with GID/GIDNOS; their Axis I diagnoses included occupation problem, adjustment disorder, and transvestic fetish. A majority 72% (N = 65) only manifest GID/GIDNOS on Axis I. More than 50% of the veterans who had undergone SRS were described as GID resolved. Eleven (17%) had a current substance-use problem other than tobacco; among these, 2 had more than one substance-use problem.

tended to have chronic medical problems. Two had a history of thrombosis associated with estrogen use. One veteran seeking SRS attended the diagnostic interview in a wheelchair. One post-SRS veteran was blind in one eye from combat action. One veteran had a record reecting multiple suicide attempts, parasuicidal behaviors, chronic PTSD, and 22 combat wounds from Vietnam service. This veteran received treatment for deep vein thrombosis presumably secondary to smoking, advanced age, and estrogen use. Individuals in this study frequently related that military service itself and the penalties associated with manifesting GID while serving were insufcient to purge their desire to change their anatomical sex. A retired senior NCO who served in a special operations role (Green Beret) for 23 months in Vietnam and who was decorated for valor revealed that she wore womens

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TABLE 4. Axis III Comorbidity in a Population of Veterans with Gender Disturbances (N = 70)
Back pain/Osteoarthritis Hypertension Coronary artery disease Headache/Migraine COPD Hyperlipidemia Obesity Prostatic hyperplasia DVT with estrogen Hepatitis C Myocardial infarction Pain syndrome Allergy, seasonal (severe) Angina Asthma Autocastration Cerebrovascular accident Chronic lymphocytic leukemia Colon cancer Congestive heart failure Crohns disease Diabetes mellitus type 2 Dysrhythmia GERD Hepatitis B Hypothyroidism Lung cancer Prostatitis Seizure disorder Sleep apnea Therapeutic anticoagulation Tuberculosis Vision loss from combat Vagotomy/Peptic ulcer disease 15 8 5 4 3 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

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ily defended targets during daylight hours. This veteran described partial relief from gender dysphoria with being able to dress as a woman and perform in plays and skits while interned in a German prisoner-of-war camp after being shot down on a mission over Europe. A World War II paratrooper related a similar risk of being discovered secretly wearing womens underwear in combat. In addition to the perils of combat and the stresses of gender dysphoria while on active duty, off-duty life was also fraught with hazards for those who could not suppress their transgender behaviors. One ofcer related that she was followed by suspicious comrades who clandestinely photographed her going to church while she was cross-dressed. This led to her premature discharge from the military and loss of career and benets after an exemplary 17 years of service. This population of transgendered veterans generally described the health care systems in the Department of Defense and in the Department of Veterans Affairs (DVA) as hostile and insensitive to their medical and mental health care needs in spite of the fact that they honorably served their country and were entitled to health care benets. Thirty-seven had attempted to utilize veterans affairs medical services, mostly for non-gender-related needs, while 33 had not attempted to utilize services in the VA in spite of being eligible for such services.

Note. Many of these veterans were diagnosed with multiple physical conditions; 31 were not diagnosed with any Axis III condition. The conditions are listed by occurrence, and then alphabetically when only one occurrence was noted. Five were not diagnosed with GID or GIDNOS, but did present with complaints of a gender identity disturbance.

DISCUSSION
Although much of the attention in the popular press regarding military service has focused on dont ask, dont tell policies related to gay and lesbian servicemembers (Halley, 1999; Stone, 2007), it is not uncommon for transgendered persons, with or without a diagnosis of a gender identity disorder, to serve their country through military service. Veterans with GID were seen from all branches of the armed forces. Indeed, Canada (Campbell, 2000), Israel (SassonLevy, 2002, 2003), Spain (Stark, 2003), Thailand (Curtis, 2004), and other countries allow known transgendered citizens to serve in uniform. The Canadian military is reported to have paid for the sex reassignment of at least one active duty military member, citing that the surgical

undergarments underneath her fatigues while deployed. In her case, the stress of continuous combat action made it difcult to resist engaging in cross-dressing behaviors. In a similar instance, a World War II bombardier secretly wore womens undergarments underneath her ight suit. She found it difcult to resist this urge and function adequately on duty without feeling a tangible connection to her female identity. Bomber crews in World War II typically ew long and hazardous missions, raiding heav-

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treatment was provided for a well-described condition with established effective treatments (Cambell, 2000). The U.S. government specifically prohibits treatments for gender or sex change, and health care systems funded by the U.S. government do not recognize or follow international standards of care for the evaluation and treatment of persons with clinically signicant gender concerns (Meyer et al., 2001). The motives for undertaking military service are many, but a repeated theme expressed by many of the MtF transgendered veterans was that they were attempting to deal with their developing recognition of transgender status by running from these uncomfortable feelings into an environment that is harshly gender dichotomous and heterosexist. This ight into hypermasculinity, although not described by all veterans interviewed (and not limited to transgendered persons who enlist in the armed forces), was common enough that this descriptive study appears to replicate a small study on this theme previously published by Brown in 1988 (this larger sample includes the veterans described in Brown, 1988). Not surprisingly, many of the veterans evaluated in a clinical setting had psychiatric comorbidities separate from any gender-related diagnosis, if there were any. This has been described in nonmilitary samples as well (Cole, OBoyle, Emory, & Meyer, 1997; Hepp, 2005). The degree of overlap of depressive symptoms between gender dysphoria/GID and a freestanding diagnosis of major depressive disorder could not be reliably discerned even by a diagnostician well versed in evaluating gender-variant persons, therefore the prevalence of a separate diagnosis of major depressive disorder should be viewed as an estimate. Over the course of this study, there has been a substantial increase in the availability of information and support services for gender-variant persons, particularly in the media and on the Internet. It is unclear what, if any, impact societal awareness and access to information and support had on this population of veterans especially with respect to lifetime desire for gender-related treatments and psychiatric comorbidities. However, the conscious and unconscious reasons the individuals had for joining military service

when they were young are likely unrelated to these more recent changes since all of the subjects had enlisted or were commissioned prior to 1990. This article has limitations that need to be considered in assessing the usefulness of the information provided. All evaluations of the veterans were performed by a single evaluator (Brown), and although interrater reliability is not an issue in this context, systematic rater bias is a potential problem. This may be partially mitigated by the level of training and experience in this specialized eld of medicine the evaluator had accrued. Active-duty service members referred for evaluation were probably less forthcoming about their histories and experiences, which would be appropriate given the punitiveness of the active-duty military environment with respect to transgender issues (see, for example, U.S. v. Guerrero, 1991; U.S. v. Modesto, 1994). This dynamic contributed to missing data and the reduction of the assessable sample to below 70 for some of the dimensions of interest, including any of the stigmatized issues (suicidality, substance use, genital self-harm thoughts, etc.). Retrospective chart reviews also have the problem of lack of uniformity in data collection and the inability to develop testable hypotheses prospectively. Much of the information solicited was of a sensitive, and possibly stigmatizing nature even for non-active-duty veterans, making estimates of certain behaviors (e.g., suicidality) derived from this review likely to be minimum estimates based on social desirability factors inherent in the responses. A comparison or control group of nontransgender veterans was not utilized in this descriptive study, therefore it is not known whether some of the ndings are consistent with the experience of being a veteran or associated with transgender status. Taking these notable limitations into account, we believe that this retrospective study documents information about transgendered veterans that has been lacking in the literature in spite of the fact that it is well known that such individuals serve in uniform in the United States and continue to request gender-sensitive health care from the Department of Veterans Affairs. Health care providers who evaluate and treat these veterans can benet from knowledge of these issues

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