US military families in Europe with transgender children left with nowhere to turn for specialized therapy
Stars and Stripes March 15, 2023
KAISERSLAUTERN, Germany — The U.S. military in Europe has cut off access to first-time transgender counseling and health care for children and teenagers, instead referring them to off-base doctors who say they can’t help.
The Defense Department’s health care system has only one pediatrician on the Continent who specializes in transgender care, which led to the decision to provide services only to existing patients, military health officials said.
Transgender care has become heavily politicized in America, where some states have passed laws restricting treatment for minors.
But the lack of care for the children of U.S. service members in Europe also means that specialized psychological counseling and screening may not be available for young people who as a group are at higher risk of suicide, depression and other mental health issues.
In many overseas military communities in Europe, even routine medical checkups can be difficult to get off base because of high demand.
Within an hour’s drive of Landstuhl, which is part of an area hosting tens of thousands of troops and their families, there are only two clinics that offer hormone treatments and other related care, said child and adolescent psychiatrist Bernd Janthur, who counsels transgender children in Dillingen.
The availability of appointments looks very bad right now even for German children because of “an enormous bottleneck in providers,” Janthur said.
Military health officials say that this care historically has been available in Europe. But a search on Tricare’s website of 75 approved providers for all medical needs within 685 miles of Landstuhl doesn’t show whether any are accepting new patients for transition-related care.
A family would work with Tricare for a referral, which is “actively working to identify additional clinics who can provide care” for pediatric transgender patients, said Landstuhl hospital spokesman Marcy Sanchez.
However, German providers say the kids would be better-served by the U.S. military community, where they should be able to receive consistent, individualized care in English.
“These are in-depth conversations about gender identity,” said Stephanie Lehmann-Kannt, a pediatric endocrinologist at Saarland University Hospital in Homburg. “It is about sexuality and intimate conversations that have to be adequately addressed in your mother tongue.”
German and international guidelines call for at least 12 therapy sessions, and often more, before the start of hormone treatment, Lehmann-Kannt said.
“It is not enough that the patient says, ‘I’d like to be a girl,’ and receives puberty blockers,” she said.
Hormone therapy with testosterone or estrogen to produce physical changes can lead to infertility, underscoring the importance of “a thorough psychotherapeutic assessment,” she said.
“You have to be careful, diligent and considerate,” she said. “And this diligence takes time and experienced providers.”
Lehmann-Kannt is one of only two endocrinologists in the area who treat transgender young people, she said. The waiting list to see her is half a year.
Out of 200 patient inquiries received in the past decade, 100 have come in the past two years, she said.
“At the moment, we can only, and barely sufficiently, service our own local patients in Saarland,” she said.
Those inquiries have included two from American families stationed in Germany, a transgender boy and one girl, she said. They were turned away because of the waitlist and the long-term care required, she said.
The Army hospital in Landstuhl stopped accepting new patients seeking transgender care in October, citing a lack of staff as a result of routine rotations.
Transgender care is long-term and involves numerous specialists, Sanchez said. The hospital’s limited resources could “lead to lapses in care, further leading to significant behavioral health impacts,” he said.
“We are confident patients (requiring transition-related care) will be satisfied with the continuity of care available at eligible and approved” host-nation facilities, Sanchez added.
Military dependents who already were being seen for that care prior to the change may continue at Landstuhl if resources allow, he said. The hospital continues to care for transgender and gender-diverse adults, Sanchez said.
No other U.S. military medical facility in Europe provides gender-affirming care to minors, said Peter Graves, a spokesman for the Defense Health Agency.
Other military clinics in Europe “are smaller sites that do not have available space, facilities or expertise to provide gender-affirming care to pediatric patients,” Graves said. They would have been referred to Landstuhl before the hospital stopped accepting new referrals, he said.
Such care includes treatments that support transgender or nonbinary people in their gender transition and is widely accepted by major medical organizations, including the American Academy of Pediatrics.
It can range from mental health counseling to medical support, such as puberty or hormone blockers.
The standards of care adopted by most professional medical associations do not include surgery for minors.
But many states, including ones that host U.S. military bases, have banned or are proposing to ban gender-affirming care for people under 18.
In South Dakota, home to Ellsworth Air Force Base in Rapid City, Gov. Kristi Noem signed a bill in February prohibiting gender-affirming treatments for transgender children. The law goes into effect this summer.
Earlier this month, Tennessee passed a similar bill.
Supporters of the legislation vary in their reasoning. Some lawmakers argue that minors aren’t ready to make decisions that could result in irreversible medical and social impacts.
Health care practitioners say some therapies do carry increased risk of infertility, for example, while other treatments do not.
Others oppose gender-affirming care based on their beliefs. In 2019, Texas Attorney General Ken Paxton urged state agencies to investigate whether a mother supporting her 7-year-old child’s gender transition was committing child abuse, the Texas Tribune reported.
Emerging academic research has linked gender-affirming treatment to improved mental health.
A small study published in February 2022 in the Journal of the American Medical Association found that treatments such as puberty blockers and hormone therapy were associated with lower odds of depression and suicidal tendencies. The study was conducted over 12 months and consisted of 104 people ages 13 to 20.
“There can be a lot of psychological stress on these young people,” Janthur said. “They can be socially excluded, harassed and criticized. As a society we’re putting a lot of pressure on them.”
Tricare, the military’s health care plan, covers hormone therapy and psychological counseling for gender dysphoria, a condition in which a person’s sex assigned at birth differs from their gender identity.
Tricare does not normally cover surgical intervention, though active-duty service members may request a waiver.
The Defense Department began allowing military dependents to receive full coverage for nonsurgical transition care in 2016.
That same year, Landstuhl began providing transgender and gender-diverse care in its pediatric clinic, hospital officials said.
Since then, the number of military youths receiving transition-related care has risen significantly.
A 2019 study in JAMA Pediatrics found that the number of transgender children and teenagers receiving care in the U.S. military health system increased from 135 in 2010 to 528 in the first four months of 2017.
“Meeting the health care commitment to our military families includes providing appropriate quality transgender care to military dependent children,” study co-author Elizabeth Hisle-Gorman told Reuters Health in 2019.
The military hospital in Landstuhl would not disclose how many transgender and gender-diverse pediatric patients it is treating.
Because such care “is not as common as a cold, for example, we would refrain from sharing information on this specific treatment at this specific location to protect patient privacy … (and) to avoid connecting the dots,” Sanchez said.
Even for military families stationed stateside, finding gender-affirming care can be difficult, since it requires “an interdisciplinary approach with multiple specialties,” Graves said.
But without increased funding and staffing, U.S. military families in Europe with transgender children, and particularly those in Germany, may not have an option for care.
“Our patients are very close to my heart,” Lehmann-Kannt said. “I don’t see a way to expand at the moment without additional providers.”
Stars and Stripes reporter Alexander Riedel contributed to this report.