Natalie Kastner, an Army veteran, was hospitalized with a severed artery in 2022 after she removed her right testicle at home without formal medical training or anesthesia. Kastner served from 2006-2008 as a combat engineer at Fort Drum, N.Y.

Natalie Kastner, an Army veteran, was hospitalized with a severed artery in 2022 after she removed her right testicle at home without formal medical training or anesthesia. Kastner served from 2006-2008 as a combat engineer at Fort Drum, N.Y. (Natalie Kastner)

WASHINGTON — A group of transgender veterans filed a lawsuit Thursday demanding the Department of Veterans Affairs provide gender-affirming surgeries.

The Transgender American Veterans Association is asking a federal appeals court judge to compel the VA to render a decision on the nonprofit’s 2016 request to reverse a regulation that excludes gender-affirming surgeries from the care that the VA provides. Gender-affirming surgery involves changing a person’s physical appearance and sexual characteristics.

The court on Thursday ordered VA Secretary Denis McDonough to submit a brief in response to the association’s lawsuit within 14 days.

Veterans seeking the surgery must now pay out of pocket and obtain care at a non-VA facility, according to the suit.

The VA already provides veterans with hormone therapy and other medical treatment related to gender dysphoria, a mental-health condition diagnosed in people whose gender identity does not match their sex at birth, the lawsuit states.

“The rule has been sitting on the VA secretary’s desk, and nothing has changed. What is the holdup?” said Rebekka Eshler, president of TAVA, which held a news conference Thursday to announce the lawsuit.

Without VA coverage, many transgender veterans cannot afford the surgery, said Eshler, who served as an Army fire-support specialist from 2012 to 2015 at Joint Base Elmendorf-Richardson in Alaska.

There are more than 160,000 veterans who are transgender, and many of them use the VA for health care, according to the association.

“Transgender veterans should not have to wait any longer,” the lawsuit states. “At the very least, VA has a legal duty to TAVA and its members to grant or deny their rulemaking petition.”

Gender-affirming surgery can cost between $50,000 and $130,000, according to the Yale Law School Veterans Legal Service Clinic, which represents TAVA.

McDonough announced in 2021 that the VA was taking steps to expand VA care to include gender-reassignment surgery, “thus allowing transgender vets to go through the full gender-[affirmation] process with VA by their side.”

“This proposed rule is continuing through VA’s rulemaking process and is being considered carefully and thoroughly, with full understanding of its importance and urgency,” said Terrance Hayes, the VA press secretary.

He said a policy change for the surgery needs to be implemented “in a manner that has been thoroughly considered to ensure services to veterans meet the VA’s rigorous standards for health care.”

The VA initiated a cost-benefit analysis of the procedure and received public comment about providing gender-affirming surgery, according to the lawsuit. Yet the VA failed to issue a decision or make the procedure available at VA hospitals.

Ann Murdoch, former TAVA president, is a retired Army lieutenant colonel and Bronze Star recipient who served for 24 years, including in Afghanistan. Prior to her retirement in 2013, Murdoch worked at the Pentagon.

Murdoch discussed at Thursday’s news conference the toll that gender dysphoria had on her mental health, and she suffered from depression and considered suicide.

“I knew from an early age that the girl on the inside did not match the body on the outside,” Murdoch said. “Fortunately, I did have private resources and support of family able to access life-saving surgical intervention.”

The lawsuit also described the experiences of Natalie Kastner, an Army veteran with gender dysphoria.

Kastner was hospitalized with severe blood loss from a severed artery in March 2022 after she removed her right testicle at home “without formal medical training,” the lawsuit states.

“I wanted to fix myself. I had no option. I had no hope,” said Kastner, a 39-year-old disabled Army veteran who lives on a fixed income. Kastner, a former combat engineer, was honorably discharged in 2008 after serving for two years at Fort Drum, N.Y.

Kastner said she acted out of desperation because she could not afford to pay out of pocket for the surgery.

“I tried to perform my own gender-affirming surgery at home, without any medical training. Were it not for emergency room care, I would have lost my life,” she said.

Support for gender-affirming surgery from the American Medical Association and American Psychiatric Association, according to the lawsuit.

“Gender-affirming care is medically necessary, evidence-based care that improves the physical and mental health of transgender and gender-diverse people,” according to the AMA.

The American Psychiatric Association has stated “medical research demonstrates the effectiveness and necessity of mental-health care, hormone therapy and sex reassignment surgery for many individuals diagnosed” with gender dysphoria.

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Linda F. Hersey is a veterans reporter based in Washington, D.C. She previously covered the Navy and Marine Corps at Inside Washington Publishers. She also was a government reporter at the Fairbanks Daily News-Miner in Alaska, where she reported on the military, economy and congressional delegation.

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