The Warrior Identity: LGBTQ+ Military Service Members
By Z Paige L’Erario, MD; Roshni Patel, MD, MS; Suzanne Marmo, PhD, LCSW, APHSW-C; and David Vincent, PhD
Social Work Today
Vol. 23 No. 2 P. 12

US military service members are often associated with a warrior identity.1 The image of a lone male soldier on the battlefield traditionally has been reinforced by recruiting initiatives and military imagery to match that social construction. However, our perceptions and expectations of who participates in military service is changing.

The number of LGBTQ+ young adults and adolescents is increasing. As many as 1 in 5 people in Generation Z identify as LGBTQ+, and 1 in 20 identify as transgender alone.2,3 For social workers who specialize in work with veterans, these are important data to inform our practice, as Generation Z represents the greatest number of incoming recruits into the United States military.4 Therefore, the question should be asked: What policies have the US military implemented to protect our LGBTQ+ service members and veterans?

Demographics of LGBTQ+ Military Personnel
Much of the research that seeks to understand the experiences of transgender and gender nonconforming service members has traditionally come from an examination of all LGBTQ+ military personnel and veterans as one group. Despite the vast differences in the lives and experiences of these distinct populations, the shared experience of marginalization and stigma has contributed to the frequent categorizations of these diverse groups as one population.

According to an analysis of US census and military enlistment data, credible estimates indicate that approximately 79,000 LGBTQ+ service members are serving in the diverse branches of the US armed forces, and an additional 1 million LGBTQ+ individuals are identified as veterans.5,6 Precise statistics related to the exact number of LGBTQ+ service members and veterans have not been available due to the legacy of discrimination within the culture of the Department of Defense, including the Veterans Health Administration (VHA).

As the largest health care provider for LGBTQ+ community members in the United States, the VHA has responded to calls to improve data collection related to health disparities experienced by LGBTQ+ service members and now includes questions related to self-identified gender identity and sexual orientation within VHA medical records.7,8 However, several quality improvement studies have shown that these identifier fields are not completed by the majority of medical providers, and transgender veterans are often less comfortable than cisgender veterans to answer any questions related to their gender identity.7

Despite a reluctance to disclose gender identity that pervades military culture and the armed services’ history of harmful LGBTQ+ exclusionary policies, it’s well documented that LGBTQ+ community members have been serving in the US military since the Revolutionary War.9 Additionally, research has shown that transgender persons actually serve at higher rates than expected from the general population, with recent research showing that up to 20% of transgender persons have a history of military service.4,10 There are an estimated 6,000 to 15,500 transgender service members and 134,000 transgender veterans.4

It’s important to consider intersectionality in demographic discussions of health care for the LGBTQ+ communities, given the historical impact of structural racism in the VHA and the high overlap of LGBTQ+ identity with racial and ethnic minoritized identities in the United States.11,12 Unfortunately, there are scant data examining health outcomes in military personnel that address the intersectional experiences of those who hold both an LGBTQ+ identity and a racial or ethnic minoritized identity. Based on the existing literature on race and ethnicity in military personnel, it would be expected that LGBTQ+ community members of color would increasingly be affected by social determinants of health compared with white LGBTQ+ military personnel.13,14 While there is heterogeneity among studies in categorization and representation of race and ethnicity, it appears Indigenous or Black and Hispanic military personnel postdeployment are at particularly high risk for the adverse psychosocial outcomes of structural disparities within the military.15 More research is needed to examine the unique health care needs and disparities experienced by LGBTQ+ military personnel from communities of color.

Historical and Current Policies for LGBTQ+ Military Personnel
Both cisgender LGBQ and transgender service members share a history of being banned from openly serving in the US military due to the now-discredited belief that they were somehow medically or psychologically unfit for service.4,16 Such characterization, when enforced with public policy, contributed to shared experiences of secrecy or “closeting” amongst LGBTQ+ veterans for protection from a persistent military culture of stigmatization, bias, discrimination, and harm.4,9

Department of Defense policies have often criminalized LGBTQ+ identity.17 In 1981, the US Department of Defense issued a policy that noted: “Homosexuality is incompatible with military service.” As a result, many LGBTQ+ service members were pressured to exit their military service on their own accord or were victims of entrapment by other service members in order to end their military service. In 1993, the Clinton administration issued a directive to the Department of Defense known as Don’t Ask, Don’t Tell (DADT), which prohibited military officials from asking potential recruits and active military service members about their sexual orientation, but did not include any specific directive related to gender identity. During the era of DADT, service members who shared their sexual orientation or gender identity publicly were discharged with less than honorable status. It’s estimated that more than 12,000 service members were dishonorably discharged prior to the repeal of DADT.18 The 2011 repeal of the DADT policy ended the ban on open lesbian, gay, and bisexual military service members but was not inclusive of transgender service members. A transgender ban on military service persisted until 2016 (and again from 2019 to 2021) but was rescinded in 2021 to permit those who do not identify with their biological sex to both enlist and serve in the military. Despite these examples of more progressive policy related to permission to enlist and serve openly in the armed forces, the legacy of the Department of Defense’s history of exclusionary practice remains embedded in many aspects of military culture.

The military’s legacy of harm directed toward LGBTQ+ military personnel has contributed to the widespread problem of less than honorable discharge status for a large number of veterans who identify as LGBTQ+ community members.9 Honorable discharge status is an important factor for healthy aging, as it entitles retired service members to income, health care, supportive services, and other resources that can help provide needed support for veterans across the lifespan. Therefore, retirement from the armed forces with honorable discharge status can serve as a protective factor against risk factors disproportionately experienced by LGBTQ+ veterans, such as housing instability, food and financial insecurity, substance abuse disorders, poor health outcomes, and mental illness.19,20 While the exact number of veterans who have been discharged due to their LGBTQ+ identities with less than honorable status following successful and meaningful military careers is unknown, it’s believed that more than 114,000 LGBTQ+ service members have been dishonorably discharged since World War II.21

On the federal level, the option to improve and expedite the process for application for status upgrade was promised on the 10th anniversary of DADT in 2021 for those LGBTQ+ veterans discharged with less than honorable status. However, since that time, veteran advocacy groups report that most LGBTQ+ veterans who chose to apply are still awaiting a status upgrade and have not been able to access federal benefits.22

On the state level, legislation through Restoration of Honor Acts has been passed in several states to authorize the restoration of some state-based veteran benefits to those who were other than honorably discharged due to LGBTQ+ identity and for those who have experienced mental health problems due to PTSD and sexual military trauma. Restoration of Honor Act states such as Rhode Island, New York, Connecticut, Illinois, Colorado, New Jersey, and California have also increased outreach to LGBTQ+- and veteran-serving community agencies in an attempt to reach those unfairly discharged.23 While state level benefits vary from state to state, benefits are limited to the state in which the veteran applied and are not transferable across state lines. More importantly, Restoration of Honor Act eligibility does not change a veteran’s official status of discharge federally, which instead requires review by the Department of Defense. These state policies do not guarantee increased access to federal benefits from VA, such as health care, home loans, pension, or military burial.22

Many LGBTQ+ service members who may be eligible continue to be unaware that they have the ability to apply for discharge upgrades.8 For some veterans, this information may not be readily available, or they may not have access to this type of assistance. Many veterans have found the application process complicated and onerous or retriggering of the trauma they experienced while in the military and related to their discharge.

Impact of LGTBQ Identity on Military Service
There is no evidence that LGBTQ+ identity negatively affects military service. Nonaffirming policies such as service bans and gender-affirming health care restrictions for transgender military personnel have cost the military more than it would have spent had these service members been allowed to openly serve and undergo gender transition, as desired.4,24,25 Inclusion of openly identifying LGBTQ+ community members has resulted in few, if any, negative consequences to military readiness, unit cohesion, recruitment, and retention.1 Further, social studies of self-disclosure by transgender veterans show that military personnel are more likable by their peers after disclosure of their transgender identity was made.26

Psychosocial Health of LGBTQ+ Military Personnel
US military service members and veterans experience an increased risk for mental health conditions compared with civilians or the general population. Military service has been associated with higher rates of mood disorders, suicidality, PTSD, eating disorders, and substance abuse disorders.27-33 The sequelae of mental health disorders in our military personnel cost the United States billions in direct and indirect expenses.31 Indirect expenses incurred by military personnel with mental health conditions include higher rates of attrition, absenteeism, occupational disability, impaired social functioning, and reduced health-related quality of life.31

The adverse psychological outcomes observed in military personnel have been attributed to a combination of various psychosocial stressors introduced within the unique lived experiences of military service members and veterans. First, military service members experience high rates of trauma, both military and nonmilitary related. These experiences include combat-related trauma, housing instability, military sexual assault, and a high incidence of reported histories of childhood abuse or intimate partner violence.28,29 Second, military service introduces disruptions in the service members’ previous psychosocial support systems, such as family and friends, both during active service and when returning home. Following completion of military service, social exclusion for veterans often occurs as a result of mental health sequelae of trauma experienced during active service.28,29,34 This transition from active service to veteran status is a particularly vulnerable time for military personnel, especially for those with physical impairments from their time in service.29,35 Third, negative coping mechanisms, such as eating disorders and alcohol and substance misuse, are more prevalent in military personnel. These adverse health behaviors mediate the relationship between military service and increased risk for mental health disorders, particularly higher among LGBTQ+-identifying military personnel.32,33,36

Military personnel of all ages who identify as LGBTQ+, particularly those from communities of color, are at higher risk of experiencing discrimination and adverse mental health consequences from both preventable and unpreventable traumatic experiences during military service. 24,25,33,37-46 Within the LGBTQ+ veteran community, transgender service members are more likely to have experienced discrimination, sexual assault, and homelessness, along with the subsequent adverse mental health outcomes from these experiences.1,10,34,41,43,44,46,47 In-depth interviews of transgender military personnel demonstrated themes of difficulty accessing health care, fear of consequences, and the importance of the therapeutic relationship.4 Further, there is a generally increased perception of mental health stigma in the military, likely decreasing the disclosure of and the treatment-seeking for mental health conditions.30,37 The higher risk of mental health conditions in LGBTQ+ military personnel has been associated with perceived prejudice, lack of psychosocial support, and increased exposure to victimization and violence.24,25,38,48

Research has shown that transgender military personnel have difficulty accessing health care and fear of consequences that may result from requesting gender-affirming care.4 Therefore, it may not be surprising that nearly 97% of transgender veterans undergo gender transition procedures after leaving the military.10 These factors are important to consider since transgender people identify in the military in greater numbers than the general population but have not yet been able to freely access surgical options for gender-affirming care from veteran health services.4

Neurobiological Health of Aging LGBTQ+ Military Personnel
Little is known about the neurobiological health of aging LGBTQ+ military service members and veterans. In the general population, the burden of neurodegenerative diseases such as Alzheimer’s and Parkinson’s has increased in recent decades, and this trend is anticipated to continue due to our aging population.49 Veterans have special risk factors for developing brain disorders with aging, including higher rates of traumatic brain injury and PTSD, which are independently associated with risk for Parkinson’s disease and dementia.50-52 Additionally, LGBTQ+ military veterans have increased risk factors for cerebrovascular disease, including higher rates of mental stress, smoking, and physical disability compared with nonveteran peers.53 Depending on their period of service, veterans may have had toxic exposures that can further increase their risk for neurological illness, such as higher rates of Parkinson’s disease and dementia amongst Vietnam-era veterans with Agent Orange exposure,54,55 and a higher rate of amyotrophic lateral sclerosis amongst Gulf War veterans.56

Prior studies of LGBTQ+ veterans relied on International Classification of Diseases coding for gender identity disorders to identify transgender individuals57 or natural language processing to identify documentation of cisgender LGBQ military personnel in the clinical notes.57,58 They show that transgender veterans have higher rates of Alzheimer’s disease and cancer44 compared with cisgender veterans. When assessing factors associated with higher COVID-19 severity amongst veterans, minoritized sexual orientation was associated with greater prevalence of stroke, COPD, and asthma.59 Taken together, these studies suggest that LGBTQ+ veterans may have unique health risks that can influence brain health and aging. However, more work needs to be done to better characterize these risk factors and assess their interaction with the psychosocial environment.

VHA Efforts to Improve LGBTQ+ Health Care
Recently, the VHA has made encouraging efforts to improve health care for LGBTQ+ veterans. A 2020 report by the US Government Accountability Office showed there was inconsistent documentation of data regarding sexual orientation and gender identity in the EHR.17 As a result, the addition of formal sexual orientation and gender identity fields in the chart was made in 2022. Previously, medical—but not surgical—gender-affirming treatment was provided by the VHA. In 2021, Secretary of Veteran Affairs Denis McDonough announced that the VHA planned to include gender-affirming surgical services for veterans;60 however, these programs are still being developed. Additional efforts have included a nationwide e-consult program to improve access to gender-affirming care for veterans in remote or underserved regions,61,62 patient advocacy and empowerment programs,63 and educational programs to improve transgender health competency amongst providers, and the appointment of an LGBTQ+ Veteran Care Coordinator in every VHA health care system.64 Social workers who work with LGBTQ+ veterans should educate themselves on these efforts and support the expansion of new ways to provide equitable care for LGBTQ+ veterans in the future.

Implications for Social Work Practice
Social workers who are interested in addressing social injustice and promoting equitable care for LGBTQ+ service members and veterans have several options. To improve micro practice, social workers can attend trainings such as those offered by local LGBTQ+ community agencies or through VA, which offers free online and on-demand educational programs about best practices in LGBTQ+ health care. Social workers who work with veterans should make sure they are including questions related to gender identity and sexual orientation into their assessments and providing clinical support and assistance with navigating the health care system, which is often perceived as complicated and bureaucratic. To help veterans advocate for services, reinstatement of benefits, or gender-affirming health care services, social workers can collaborate or refer to the nearest LGBTQ+ veteran care coordinator assigned to that veteran’s health care system.

Within their organizations, social workers can advocate for staff and leadership training related to providing inclusive care for their LGBTQ+ veterans, particularly gender-affirming care. Social workers can also document instances in which disparities in care are experienced by LGBTQ+ veterans and share them with agency administrators, professional organizations, and community-based LGBTQ+ veteran advocacy organizations.

To improve macro practice, social workers who are members and leaders of professional organizations can advocate for these groups to take policy positions on pending legislation to support the implementation of LGBTQ+-affirming policies and improve LGBTQ+ services within the VHA. Social workers who reside in states that do not have Restoration of Honor Acts signed into law can contact state level representatives to support similar legislation. On the federal level, social workers can advocate for implementation of recent changes to policies that support gender-affirming health care to ensure that transgender service members are able to receive safe coordinated continuum of care that is both LGBTQ+-inclusive and veteran centric.

Conclusions
Domestically, an unnecessary battle ensues in the United States as to what defines a woman or a man. There is no evidence that acceptance and affirmation of LGBTQ+ service members’ identities harm military operations. It is clear that nonacceptance of LGBTQ+ military personnel harms our service members and veterans and costs the system more money than would allowing for our LGBTQ+ personnel to openly serve with equal treatment. Therefore, our LGBTQ+ military personnel, particularly those from communities of color, are warriors battling additional injustices that other military personnel do not face. Hopefully, these warriors will find equal representation to express their authentic identities within the military.

It’s time to put politics aside and increase access to affirming services and protections for our LGBTQ+ military personnel. Social workers can lead the critical examination of systems of privilege in policy and law that have prevented equitable care for those LGBTQ+ service members and veterans who have served this country.

— Z Paige Lerario (they/them/Doctor), MD, is a vascular neurologist and transgender activist. They are a graduate student of social service at Fordham University, and the vice chair of the LGBTQI section of the American Academy of Neurology. Follow their blog at greenburghpride.org.

— Roshni Patel, MD, MS, is a neurologist at Jesse Brown VA Medical Center and assistant professor of neurology at Rush University in Chicago. She has special interest in LGBTQ+ health in neurology, Parkinson’s disease, and teleneurology.

— Suzanne Marmo, PhD, LCSW, APHSW-C, is an associate professor of social work at Fairfield University. She’s been a licensed social worker since 2001 and a certified advanced palliative and hospice social worker since 2019. Marmo’s clinical expertise includes medical and oncology social work, hospice, palliative care, and working with older adults. Her research interests include palliative and hospice social work, the role of social work in health care organizations, social justice, and inequities in health care systems.

— David Vincent, PhD, is the chief program officer with SAGE, where he provides vision, oversight, and leadership to all direct service programs, including care management, housing, behavioral health, and SAGE Center programming. He’s responsible for the conceptualization, development, growth, and management of a broad portfolio of largely government-funded service programs for LGBTQ+ older adults.

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