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28 | COLUMBIA SOCIAL WORK REVIEW, VOL. X 

INCLUSION AND READINESS: IN SUPPORT OF 
LGBTQ-AFFIRMING MILITARY HEALTH CARE

ADAM PIERSON MILANO

Author’s Note: For the purposes of this paper, the acronym LGBQ 
(lesbian, gay, bisexual, queer) is used to discuss policy that does not 
specifically address transgender service members. The acronym LGBTQ 
(lesbian, gay, bisexual, transgender, queer) is used when individuals 
who identify as transgender are impacted by the policy or culture 
discussed. As the author, I recognize and respect that even LGBTQ does 
not incorporate all sexual orientations and gender identities. 

Mercurial policy shifts concerning the gender identity and sexual 
orientation of individuals serving in the United States military have 
adversely affected the quality of health care offered to service members who 
identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) directly 
impacting unit readiness. A lack of LGBTQ-affirming services within 
the military health care system compromises the health and well-being 
of LGBTQ service members, which is symptomatic of the exclusionary, 
heteronormative culture fostered by decades of discriminatory policy. The 
historic inequity within the military and its impact on the relationship 
between LGBTQ service members and military health care providers 
(MHCPs) must be addressed to rectify the ongoing health care disparity. 
Moreover, policies and LGBTQ-affirming practices that empower service 
members and foster inclusivity must be implemented to strengthen the 
military as a whole.

THE HISTORY OF LGBTQ SERVICE POLICY
During World War I, the U.S. military criminalized sodomy and 

explicitly prohibited “homosexual conduct” by service members (Connell, 
2017). The first outright ban of LGBQ service members was imposed 
during World War II, when the surgeon general of the U.S. Army classified 
homosexuality as a justification for disqualification from military service 
(Bérubé, 1990; Bailey & Barbato, 2011). After World War II, lesbian, gay, 
bisexual, and queer (LGBQ) service members were discharged under a 
pseudo-psychological pretext known as a “blue discharge” (Bailey & Barbato, 
2011). At this time, the military did not address transgender identity in its 
policies. In 1962, a new policy facilitated the discharge of service members 
based on assumed homosexual identity, regardless of whether they had 
engaged in sexual activity with a member of the same sex (Connell, 2017). 
The discharge of service members was left to the discretion of commanding 
officers. Beginning in 1981, the Department of Defense’s standard protocol 



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LGBTQ HEALTH CARE IN THE U.S. MILITARY

was to discharge all service members who engaged in homosexual acts 
(Connell, 2017). 

The Don’t Ask, Don’t Tell (DADT) policy, an effort to promote inclusivity 
within the armed forces, was enacted in 1994, despite fierce opposition 
from the Senate and military leadership (Bailey & Barbato, 2011). DADT 
allowed LGBQ individuals to serve in the military, provided that they did not 
disclose their sexual orientation. This repeal did not apply to individuals that 
identify as transgender.  In actuality, discharging service members remained 
common practice upon reveal of their actual or perceived nonheterosexual 
orientation (Bailey & Barbato, 2011; Goldbach & Castro, 2016). This policy 
bred a “witch-hunt” mentality, in which service members could report 
to superiors any service member suspected of being LGBQ (Bailey & 
Barbato, 2011). This practice negatively impacted unit cohesion because it 
undermined the value of teamwork inherent to the military. The Don’t Ask, 
Don’t Tell Repeal Act of 2010 overturned DADT and allowed LGBQ service 
members to serve openly, meaning they were able to be honest about their 
personal lives with their units. Prior to this repeal, service members would 
often have to lie about their social lives, live off-post, and avoid bringing 
partners to military functions. This repeal did not apply to service members 
who identified as transgender. Shortly thereafter, the Department of Defense 
began offering family benefits to same-sex spouses (Department of Defense, 
2013).

CURRENT POLICY
The ongoing debate regarding LGBTQ service policies specifically 

impacts the transgender community.  In 2012, the Department of Defense 
released formal instructions barring individuals with a history of 
psychosexual conditions, “including, but not limited to, transsexualism, 
exhibitionism, transvestism, voyeurism, and other paraphilias” from 
enlisting in the military (Department of Defense, 2012). This ban 
on transgender service was officially repealed in 2016 by the Obama 
administration, which emphasized that transgender individuals are fit to 
serve and already do so in other countries (Connell, 2017). The Department 
of Defense is actively recruiting, training, and retaining transgender 
service members despite continued efforts to prohibit their service, 
including the Trump administration’s efforts to reinstate the ban (Shane, 
2018). Transgender individuals enlist at twice the rate of their cisgender 
counterparts, which some researchers and personal accounts attribute to 
a desire to embrace the societal construct of masculinity (Connell, 2017; 
Goldbach & Castro, 2016; Herzog & Orabona, 2014; Kemp & Del Monte, 
2017). The reinstatement of the 2012 ban would limit which transgender 
service members are permitted to serve based on the length of time each 
individual has identified as transgender and on potentially necessary 
medical accommodations related to gender identity (Seck, 2018).   



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LGBTQ HEALTH CARE IN THE U.S. MILITARY

Opponents of the ban question the justification for its implementation. 
Some high-level military leaders, bolstered by pseudoscience, claim that 
the inclusion of LGBTQ service members has a negative impact on morale 
(Bailey & Barbato, 2011). Contrary evidence shows that, in fact, a ban on 
transgender service would adversely affect unit morality, retention, and 
readiness, as evidenced by the “witch-hunt” culture during the period 
of DADT (Barnes, 2018; Bailey & Barbato, 2011). This policy battle has 
perpetuated confusion among the ranks regarding the state of current 
regulations and has created a daunting environment for transgender service 
members. For instance, service members who identify as transgender 
and who have recently disclosed their gender identity may fear negative 
repercussions if the Trump administration were to reinstate the ban.

IMPLICATIONS FOR HEALTH CARE
Though DADT has been repealed, LGBTQ service members’ distrust of 

military health care providers (MHCPs) remains. MHCPs serve in the dual 
roles of clinicians and officers. As officers, MHCPs are required to report 
medical findings that disqualify patients from service eligibility. Under the 
DADT policy, if a patient informed a MHCP of their LGBTQ identity, the 
MHCP was required to report the patient and, in some instances, to classify 
them as unfit for service (Biddix, Fogel, & Black, 2013). Considering that 
the ban on transgender service may be reinstated, it is likely that many 
transgender service members will be reticent when interacting with 
MHCPs, as being open about their gender identity can disrupt their ability 
to serve (Goldbach & Castro, 2016). In a study examining comfort levels of 
LGBQ service members with regard to the military health care system, 30% 
reported feeling discomfort when discussing their gender identity, sexual 
orientation, or sexual health with their MHCP (Biddix et al., 2013). The 
study found that 44% of gay and bisexual male participants believed sexual 
orientation was a factor in the care they received from the military (Biddix 
et al., 2013).

Many LGBTQ service members waited several years after the repeal of 
DADT to come out to their units, for fear of bullying, denial of promotion, or 
discharge (Bensahel, 2012). One notable study revealed that 45% of LGBTQ 
service members chose not to disclose their sexual orientation to MHCPs 
and 75% believed that their MHCP presumed that they were heterosexual 
(Stebnicki, Persko, & Thomas, 2015). Many LGBTQ service members also 
reported that they avoided seeking health care for fear of discrimination 
(Stebnicki et al., 2015). Notably, LGBTQ service members are likely to have 
poorer physical and mental health—including increased risk of conditions 
such as depression, posttraumatic stress disorder, and alcohol and/or 
other substance use—than the health of their heterosexual and cisgender 
counterparts (Stebnicki et al., 2015; Shrader et al., 2017). Further, LGBTQ 
service members attempt suicide at a rate 2.5 times higher than non-LGBTQ 



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LGBTQ HEALTH CARE IN THE U.S. MILITARY

service members (National Defense Research Institute, 2010). 
New recruits may be drawn to enlist because of the alluring, 

comprehensive military health care benefits to which they are entitled 
during and after service. However, until the repeal of DADT, service 
members who were entitled to full retirement benefits—accrued over 20 
years of service—but who were discharged for being LGBTQ would have 
to reenlist to receive benefits. Likewise, if a ban on transgender service is 
reinstated, transgender individuals who lose their active duty or reserve 
status would be denied military health insurance until a policy change 
allows them to reenlist. The nature of their discharge may also negatively 
impact their right to receive lifelong health coverage from the Veterans 
Health Administration (VHA) (Bailey & Barbato, 2011). Should the military 
continue to employ transgender service members, LGBTQ-affirming 
measures must be expanded to cover all LGBTQ service members, both 
active and veteran, across all military facilities.

RECOMMENDATIONS
Transgender service members face unique barriers in receiving quality 

health care. An estimated 250,000 LGBTQ service members and veterans 
utilize VHA services, including roughly 5,000 who identify as transgender 
(Kauth & Shipherd, 2016). In 2018, the Veterans Administration (VA) issued 
a directive to use inclusive language, providing more deferential care to 
veterans who identify as transgender or intersex by addressing patients 
by their preferred names and gender pronouns (Department of Veterans 
Affairs, 2018). Though this policy cannot completely assuage the discomfort 
of many LGBTQ service members in VHA environments, it is a step in the 
right direction and should be adopted by the entire military health care 
system in order to support and care for LGBTQ service members (Stebnicki 
et al., 2015). 

MHCPs and military social workers play an integral part in changing 
the way the military supports LGBTQ service members; both roles have 
the unique capability to engage at multiple levels of the military and to 
positively change how LGBTQ service members receive care. Military 
social workers are trained to provide necessary support, counseling, 
and education to military personnel and their families; however, there 
is room for improvement in how to sensitively and effectively work 
with LGBTQ service members. While seminars and ethics training may 
provide a foundation, LGBTQ service members deserve care from those 
who are specifically trained to meet their needs. Strebnicki et al. (2015) 
provide several suggestions that can be adapted specifically to social work 
supervision, including seeing LGBTQ patients regularly during internships 
and post-education training, ensuring that supervision includes discussions 
about LGBTQ experiences, and learning directly from those who have been 



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LGBTQ HEALTH CARE IN THE U.S. MILITARY

the recipients of this care in the past. A standard of care should then be 
established to ensure that all service members are receiving the highest 
possible level of support, regardless of where they are stationed.

MHCPs and social workers must then address the distrust between 
LGBTQ service members and MHCPs. The therapeutic alliance between 
clinician and service member must be rooted in mutual trust, which has 
been eroded in the military by the former policies that mandated MHCPs 
to report evidence of LGBTQ identity. Moving forward, in order to provide 
affirming care, MHCPs must acknowledge the historically problematic 
power dynamics of the relationship and allow this awareness to shape 
the ways in which they interact with and provide care for LGBTQ service 
members. For example, not assuming service members’ sexuality or gender 
identity and changing the language around health care can provide a more 
welcoming hospital environment and thus healthier LGBTQ service 
members. Each unit of MHCPs should also include a subject matter expert 
on anti-oppressive practice to allow for direct peer-to-peer education.  

Furthermore, improving health care outcomes for LGBTQ service 
members may also occur outside of the medical department. Due to social 
work officers’ unique position within military structure, they are able to 
engage directly with unit leadership. They should take the initiative to 
conduct anti-oppressive trainings for these leaders, therefore prioritizing 
and normalizing the inclusion of LGBTQ service members. Educating all 
members of the military in anti-oppressive best practices could help to 
mitigate negative mental health outcomes for LGBTQ service members that 
are rooted in living and working in environments that contain unaddressed 
stigma, stereotyping, and homophobic undertones (Stebnicki et al., 2015). 
If both commissioned and enlisted leaders incorporate inclusive language 
into their daily lives, the rest of the unit, and thus the culture, will follow.

CONCLUSION
In conclusion, vacillating policy changes have had negative effects on 

readiness and inclusion within the U.S. military. The whims of politicians 
should not negatively impact the health care provided to service members 
and veterans, regardless of their sexual orientation and gender identity. 
While society at large has made great strides toward acceptance and 
inclusion of the LGBTQ community since the DADT era, the military 
community and government policy still lag behind. Under the Obama 
administration, the military took steps toward greater inclusivity with 
the repeals of both DADT and the ban on transgender service, yet current 
political leaders are working to revert to an earlier era by reenacting 
previous bans that were discriminatory and detrimental. However, there 
is hope for the future of LGBTQ service members. VHA health directives 
prioritize inclusivity and work towards providing the care that veterans may 



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not have been able to access during their active duty service, and continuous 
advocacy by military social work officers can help to change military culture 
both within and outside of the medical tent. Perhaps the next administration, 
alongside Congress, will ally with this rising generation of social workers to 
facilitate the establishment of a more inclusive military, propelled by health 
care professionals who are educated and committed to LGBTQ-affirming 
practices and sustained by those who will never stop fighting for the care 
they deserve from the country they love. 



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ADAM PIERSON MILANO is a two-year student on the Clinical Track 
with a focus in Health, Mental Health, and Disabilities. Adam created his 
current field placement as the Life Skills Instructor at the Naval Academy 
Preparatory School in Newport, RI. He received his Bachelor’s degree from 
Middlebury College and is originally from New Jersey. Adam serves in the 
443rd Civil Affairs Battalion, U.S. Army Reserves.


