The transgender military athlete

This chapter will attempt to translate aspects of military service to a nonmilitary medical community to inform medical providers caring for transgender persons before entering military service or already serving in the military. The military is a physically demanding line of work, and for this reason, one should consider service members as athletes with specific job-related physical requirements. This chapter is from a United States perspective, and some aspects may not be applicable in other countries. Additionally, as the topic of transgender athletes has and continues to evolve, these authors acknowledge that the discussion in this chapter may be irrelevant in the future. This chapter will not touch on specific details regarding military transgender policies.

All service members in the military are assigned a military occupational specialty (MOS). All MOS is currently open to all service members regardless of gender from the United States military perspective. A military MOS is a position description (PD) outlining the training received and the physical requirements a particular job requires for the service members to perform their day-to-day job. At the individual level, any person capable of meeting MOS entry criteria, including physical demands, can serve in any MOS. However, all service members will conduct activities, including physical work, outside of their MOS as ordered to accomplish the unit Commander’s mission.

While the physical requirements vary by MOS, all service members must meet specific military service physical criteria. The military most commonly measures the overall fitness of a service member through a periodic physical fitness test. The physical fitness tests are standardized but vary between nations and between the various services of the same country. There may be gender and age-specific criteria for minimal physical fitness test standards. Additionally, the components of physical fitness tests may change if the military service updates what is measured to ensure that basic physical fitness tests meet the requirements for modern military operations.

The physical requirements required for an MOS vary between MOSs. In some cases, a physically demanding job may not be immediately apparent when viewed from a civilian perspective. The combat arms MOSs are more physically demanding than combat support MOSs. Examples of combat arms MOS would be infantry, armor (tanks), and artillery (cannons). Examples of combat support MOSs would be logistics and medical support. At first, a cook may seem minimally demanding until one explores the tasks required of the MOS in the field environment, such as setting up and takedown of a field kitchen or moving heavy boxes of mass food supplies on and off trucks.

Finally, individual military units or training courses may have physical requirements that exceed the military’s minimal standards or MOS-specific standards. For example, an infantry unit may have a running standard that requires a person to run 5 miles at an 8-minute mile pace. As another example, the pull-up requirement for entering airborne school (military parachute) is unique to that skill training. Before starting airborne training, service members must prove they can complete a pull-up.

With changes in testosterone exposure during gender transition, some MOSs may be more difficult or easier to engage. The infantry soldier transitioning from male to female may find the physical requirement of the MOS more difficult after the transition. Conversely, a female transitioning to a male service member may find that their physical capacity increases to facilitate more physically demanding MOSs, military training, or course selection.

There is no high-quality medical literature that increasing testosterone will change the musculoskeletal injury pattern risks for females transitioning to male service members. A 2020 study titled “Identification of Risk Factors Prospectively Associated With Musculoskeletal Injury in a Warrior Athlete Population” identified the female gender as having a 3.6 odds ratio and a relative risk of 1.8 (both 95% confidence interval) [ ]. In light of this, in the opinion of these authors, intuitively and based on expert opinion in the sports medicine field, injury risk positively correlates with increased muscle mass placing increased demand placed on the same bone structure [ ]. For instance, stress fractures may increase as the demand on bone structure and density increase (i.e., gynecoid pelvis). This opinion should be cautiously viewed as a hypothesis only without well-conducted studies to support this view. Conversely, while current literature demonstrates increased overuse injury risk to female service members during basic training [ ], there is no robust evidence to suggest transgender females carry the same risks. At this time, the increased risk does not equal injury, and transgender service members’ musculoskeletal injuries are managed no differently from cisgender service members.

Another consideration is resources available at the service member’s location, both in deployed and training environments. Service members may be required in locations not conducive to medication storage and resupply considerations or frequent medical provider access. The austere nature of military operations may require service members to live in circumstances without access to electrical power or refrigeration. Military foods are shelf-stable, and with access to drinkable water, service members can live in austere environments for extended periods. For this reason, initial entry and retention requirements for military service have a high bar for the overall health of the service member.

In various locations, including deployed austere environments, close access to medical specialists, such as endocrinologists, or behavioral health may be limited or infrequent. Lab services in austere locations are also limited. If a medical emergency necessitates medical support that exceeds that available at an austere location, then there are evacuation procedures to bring the service member to the appropriate level of medical care. Specific MOSs, by the nature of their operational environment, are not conducive to medical evacuation or medical resupply, regardless of the emergency. As an example, sea duty, in particular submarine duty, would fall into this category. Evacuation procedures are for emergencies and have an inherent risk associated with patient movement in a nonpermissive environment. Hence, medical providers are obligated to screen all personnel deploying for potentially limiting medical conditions prior to deployment to mitigate the risk of unnecessary evacuations.

Screening guidelines for service personnel may vary by country, the branch of service, and even travel location. Within the US Military, medical providers utilize specified standards to screen service members. These standards consider what resources are available within that area of operations for the service member and mitigate health risks to maximize the overall success of the mission.

Military commanders must also consider several factors when incorporating transgender service members within their formation. While gender identity, gender anatomy, and sexual preference are exclusive, it is a leader’s responsibility to provide equal accommodations and comfort within the operational limitations of the military operation. Acknowledging that no two military operations are identical, the accommodations available on one mission may not be feasible on the next mission. Similarly, collegiate and professional coaches account for different accommodations and resources between home and away games. On the other hand, military leaders face a unique challenge complicated by the austere nature of military operations. For example, in field showers, a transgender female without gender-affirming surgery may feel nonincluded by cisgender female service members.

All service members should be medically capable of conducting their end job requirements, specifically deploying and accomplishing the goals their nations require of them. More data are required to determine the risk of injury associated with hormone therapy during and after a service member’s transition. Service members who cannot deploy to an austere environment should be considered for separation from service regardless of medical reasons. Medical providers must consider the time required for transition, the gender transition process, and necessary follow-up care in the service members’ ability to safely execute their duty to mitigate medical risk in training and austere environments. Additionally, as more transgender service members join the military formation, military leaders must consider potential logistical and medical challenges in facilitating transgender service members’ overall well-being while balancing operation requirements.