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Everyone gets so caught up in how to count or budget when dieting. Let me be clear, there is no gray area here; this is very simple and it’s easy. As I talked about in “Your Survival Machine: An Owner’s Manual to Your Body,” in the Jan/Feb issue of OutServe Magazine, you should operate on a food budget. Most people understand the concept of this, but get caught up in sophisticated manuals, books, internet sites, apps for their phone…but it is very simple.

Eat Like a Diabetic
I have already given you the thought process behind eating like a diabetic to stay healthy. Now I will give you the tools to do that. First, I am going to explain some simple basics. A calorie is not just a calorie. If I tell you to eat 1,500 calories, and you do exactly as I say, but eat it all in one meal a day, you will not do well. If you take the same amount of food and spread it over the day, the same amount of calories will yield a better result. The same thing goes for what type of food you spend that 1,500 calories on.

Back to the Basics
Meals are composed of three major things: carbohydrates, protein and fat. None of these are the “villain.” Each part is a necessary essential component of food. Carbohydrates gives us energy, protein is the building block for muscle, and fat provides satiety so we don’t eat as much, and it makes food taste yummy (that is a technical term).

That being said, different goals will yield different percentages of what you should eat with these meals. For instance, for an average healthy person, we recommend 55 percent carbohydrates, up to 30 percent fat, and that leaves 15 percent protein. For diabetics, or people wanting to lose weight, I suggest 45 percent carbohydrates, 25 percent fat, and 30 percent protein. Certain performing athletes may require higher carbohydrates and protein.

Protein is NOT perfect
I constantly fight with body builders who claim they need tons of protein. Yes, while protein is the building block of muscle, eating too much of it will cause you to gain fat. Your body only has so much of a need for protein. For a normal healthy adult, you only need .8 g per kg of body weight (that is your weight in pounds divided by 2.2, for you non-European types). Body builders may have a little of an increased need, but 1 g per pound of body weight (which is commonly cited) is just too much. It is hard on your kidneys and is only causing extra work to convert it to an energy that your body can use.

Now what do I do?
So I gave you the basics; it all sounds confusing, right? .8 per kg?! We don’t want to freak anyone out by giving too much information, so for diabetics, we do what is called “carb counting.” The premise of this is that if you use common sense and keep your protein/meat at a portion of around the size of a deck of cards and limit your fat (just don’t go crazy), then you will probably be okay without any complicated counting. It is those pesky carbs that are usually the culprit for going into a deficit. So, how do I count those?

Equation Time!
You math people will love me on this one. For those of you that have to know a crude, quick way to calculate, then do this:

Your weight in pounds divided by 2.2 = ______ kg of body weight. Take that number and multiply it by 24= _____. Now for the battle of the sexes…females only: multiply that number by .9=_____. (Females require less calories to operate their bodies. Sorry ladies).

This gives us the calories our bodies need to run. It is a crude calculation, but a fairly accurate one. So now, how do we narrow that into what I talked about in terms of something you can use? For those of you who want to lose some pounds, subtract 500 from that number. To explain myself, there are 3,500 calories in 1 pound of fat. So reducing 500 a day will give us around 1 pound of weight loss a week. Don’t shrug that off—that would equal 52 pounds in one year!

Take that number of calories and multiply by .45 = _____ (This is the 45 percent of all your calories that should be from carbs). So, that gives me a number of calories from carbs. Now here is basic science…there are four calories for every gram of carbohydrate or protein. There are seven for every gram of alcohol (yes it counts!). There are nine for every gram of fat. So knowing that, we should take that number and divide by 4=____ grams of carbohydrates you need to stay at or below.

That is your MAGIC number. Take that number and figure out how many meals you can commit to a day. Re-read my first article on outservemag.org if you want to make this more successful; the more meals you can divide it into, the more successful you will be.

***

By Steve Snyder-Hill, MS, RD, LD

If I could create a pill that would solve the world’s problems, I would be a millionaire. By problems, I mean the fact that we are the heaviest we have ever been as a country.

The funny thing, there is a pill already created. The pill is called common sense and simplicity. These are the two ingredients to a successful diet and weight-loss program. In this article, I am going to highlight the need-to-know facts about dieting.

Keep It Simple

When we eat, our food breaks down into sugar. Our body does one of two things with that sugar. If our body needs it because we are exercising, it will convert it to glycogen and use it up, because that is a great fuel for exercise. If it doesn’t need it for energy for exercise it does one of the most brilliant things it can do… it turns it into fat.

People probably don’t understand that brilliant step, but let me explain. Your body is a survival machine. It has one goal, to survive. Your body doesn’t know that you will feed it again. Your body thinks every meal you eat is the last one. Fat is a dense storage form of energy that our bodies can use later if we are not eating. Once you cling to this concept, you start to understand why people who diet are crazy!

When we diet, we typically deprive our body of food; we do things that are generally extreme. That upsets your body’s energy balance. Its instinct is to kick into survival mode. Survival mode is to store fat during deprivation. So, people who complain that they are not eating and still not losing weight may start to understand this better.

Stay Grounded

The first thing we do wrong is a tendency to demonize something. It could be “carbs are bad,” or “fat is bad.” But taking any one essential nutrient out of our diet is going to lead to a survival instinct from our bodies. Fat, protein, and carbohydrates are all essential elements of a healthy diet. Fat provides satiety, which means when you eat it, you tend to feel full and not inclined to eat again for a while. Carbohydrates provide energy to fuel us through the day. Protein is an essential building block of our body and our muscles. If a diet promises something that seems too good to be true, stay away from it. If a diet claims that this is some revolutionary breakthrough science, avoid it. Nutrition is a simple concept, and we know how it works. There are no revolutions going on, except that we are getting heavier as a nation.

Know the Science

Remember, I said that food breaks down into sugar. That sugar is released into your blood. You have heard the term, “blood sugar;” well, that is exactly what it is. Stay with me on this one: your body has to get that sugar out of your blood. This is important. Sugar dumped into any fluid starts to thicken it, and that same thing happens to your blood. If you know anyone who has diabetes, this is their problem. Your body releases insulin, which has one job—to remove sugar from blood. Anything that causes your blood sugar to shoot through the roof causes a big insulin release. A big insulin release, unfortunately, also means a really efficient fat-storing machine goes into motion. So, we need to avoid our survival machines turning into an efficient fat-storing machine. The way we do that is by keeping our blood sugar at bay. How do we do that?

Budgeting

A diet should not be called a diet; it is a budget. If I want to buy an iPad, I work it into my budget. Food is the same thing. We can work things in. What we cannot do is just take things off the shelf and not expect to go bankrupt. One thing I will never do is say you cannot eat chocolate (or anything for that matter). If I say no chocolate, the only thing you think about is what you can’t have, and it makes you crazy. I am just going to see how it works into your budget. If you choose to pay the price for that and pay it off by budgeting other food or adding exercise, it is fine. It is your budget. You can have anything, but everything costs different amounts, and keep that in mind. I will teach you in the future how to figure out the costs in simple ways.

One other concept is a “cheat day.” If I made you work seven days a week and never gave you time off, you would go crazy. We all need a weekend. If, right now, you are doing seven days of bad by not watching what you eat, and you made it a goal to try to do just one day of good, you would be progressing. Once you reach that goal, you shoot for two days of good and build on that. Don’t go from zero to 100 and be left in the dust trying to figure out why it didn’t work. Trust me, if I could get people to watch what they ate five days a week and just not worry about it on the weekends, they would still make progress.

Throw Your Scale Away

I hate scales. I have helped a ton of people lose a lot of weight and build a lot of muscle. The one thing that is a constant is that people who come in and sit down and say, “I need to lose X-amount of weight for a wedding,” fail. People who set a deadline to lose fail. This is not about deadlines. This is about adapting a new way of life. If you take the principles that I introduce each month and build them into your way of life, you will be successful. Success should never be measured on a scale. First of all, we eat and drink more than 15 pounds of food and water a day. Depending on when you weigh yourself, you could have just drunk two pounds worth of water. But, like clockwork, people step on a scale and throw their hands up in the air and declare this is not working. Frustration leads to eating, eating leads to anger, and anger leads to quitting. A measure of success is to take a blank calendar and cross off every day that you feel like you made a good effort to eat well and exercise. That is your success, not a number on the scale. If you can get to the end of the year and flip through that calendar and see lots of check marks, I promise you will never need to step on a scale.

Learn to Eat Like a Diabetic

A diabetic diet should not be called such. It should be called the right way to eat. A huge spike in blood sugar can occur in one of two ways. First, we eat things that exponentially raise it (high carbohydrates, sugary drinks, etc.). Second, is that we skip meals and let our normal blood sugar drop to low levels and then eat a giant meal because we are hungry. Did you ever wonder why you fall asleep immediately after you’ve eaten a big Thanksgiving dinner? That is insulin, turning your body into a fat-storing tank because of the big meal it was just fed.

A running joke we had in college was that on any dietitian exam, we would always try to answer, “small, frequent meals.” That answer is almost never wrong for many different scenarios. That is the same thing we tell people with diabetes. The theory is that instead of a huge insulin release, we are getting smaller releases. Those smaller meals also give your body a constant flow of energy and won’t let it kick into starvation mode. If you took the exact same amount of calories and, instead of putting it into two meals, you spread it out through the day in six meals, you would lose weight eating more times through the day. This is probably the single most important thing a person can do. Six meals a day is the best. As a dietitian in a hospital, if I feed someone in a tube feed, I make it continuously feed them for 24 hours. I don’t shove it all in them in two blasts. Bodybuilders will also confirm this science: You do not skip meals. Skipping meals means muscle wasting. Keep your body out of starvation mode by feeding it.

Slow Down

Another huge concept is that people eat way too fast. CCK is a hormone that is released in your body when you eat. It has a simple function, to turn off your hunger. I hate the words, “I feel full.” If you feel full, you failed. CCK simply turns off hunger. I was helping someone lose weight, and we were talking and eating. I was intentionally making him slow down and talk while we ate. Half way through the meal, I said, “Hey, if I were to ask you if you were hungry right now, what would you say? If I said, do you want to go get something to eat, how would you respond?” He realized that his body was telling him that his hunger was shut off. He was doing what the rest of us do every day. We eat until we feel our stomach stretch and we feel full. Many weight loss programs tell people to leave the table hungry. They are not trying to starve people; they just realize we eat too fast. It takes a good 20 minutes for that hormone to work, so if you take less than 20 minutes to eat, you are not giving your body the opportunity to give excellent feedback. Also if you are eating like someone with diabetes, many times you will eat when you are not hungry. Waiting until you are hungry usually means low blood sugar. Remember these words: Eat to live, don’t live to eat!

Don’t Forget the Cheese Exercise

As a dietitian, if someone asked me how to lose weight, but they would only diet or exercise, what do you think I would tell them? Here is a hint: While I am a dietitian, I also minored in exercise physiology. Exercise is such an important aspect in all of this. I will be writing a lot of articles on that in the future, but for now know, that exercise is equally, or maybe even more important, on this journey. Exercise is something that naturally regulates serotonin, which is involved in everything from appetite regulation to depression. So, if exercise helps regulate it, start to imagine how much that can help you in this journey.

Dieting Basics

I would like to spend a second to clear up a couple things that drive me insane. If people could grasp these small concepts, the journey of weight loss would be a lot easier.

First, juice is bad. I don’t care what it is fortified with or if all-natural. Juice is sugar water. Sugar in a fluid that goes into your blood stream is going to spike your insulin levels quickly, and that is not good. Eat a fruit. Fruit has fiber and lots of vitamins. Taking the fiber out of the fruit to drink the juice is just as bad as soda.

I am going to lump soda into this same category because they are essentially the same thing. If you did not do anything different—not one ounce of exercise, not one modification to dieting—but you drank one less soda a day, exactly one year from now you would weigh 18.5 pounds less. Think about that. Over five years, that is close to 100 pounds of excess calories, and that isn’t even taking the insulin spike into account. This does not include diet soda.

Salad Is Bad

There, I’ve said it. Let me explain. Lettuce is water. Once you chew lettuce up, you have about 99 percent water and a little pulp. What used to be your gorgeous healthy looking salad is now a small glass of water and a little pile of pulp on your plate. What else do you like on your salad? We will put a little pile of cheese on the plate next to the tiny pile of pulp, add a little pile of bacon and pour some fat, gooey salad dressing over it. Would you eat that? Does it look healthy? But when I inflate that green lovely lettuce back up, we accept this as a healthy meal. Not all salads are bad. If you remember the basics—carbohydrates, fat and protein—then your salad can look better. Add some cottage cheese instead of the dense dressing. Cottage cheese will provide some protein and some fat, but not drench your salad into just a meal of fat. Adding some chicken or other lean meat also gives the salad some better substance. One of my favorite additions is beans: kidney, pinto, butter, any type are great on salads. They provide not only carbohydrates, but also protein and fiber. You can make a salad look better, but when I watch most people who are overweight eat salads, I cringe. I know why they remain overweight and puzzled that this new diet is not working.

Breakfast Is the Most Important Meal of the Day (And Also Usually Our Worst)

When we go to bed, our blood sugar slowly drops. It drops while we sleep, and when we wake up it is at an all-time low. Eating six meals a day is important, but the timing of those meals is important, as well. We cannot avoid sleeping, and it isn’t likely we will set an alarm to eat during the night, so when we eat supper at 5 p.m., if you don’t eat again until 6:30 a.m., then you’ve gone 13-plus hours without food (out of a 24-hour day). Whoever started to tell people not to eat late at night did everyone a disservice. Eating a snack before you go to bed is a good practice, but getting up and eating breakfast within 30 minutes from waking up is, too.

Another problem is that we have migrated as a country to high-carbohydrate breakfasts. Don’t’ get me wrong, carbs are not the complete enemy, but carb-loaded breakfasts are. You wake up with low blood sugar, and if you feed your body a high-sugar meal, that will kick your body into that fat storing machine again. In the 1960s, breakfast was bacon and eggs, and we cooked with lard. Today, breakfast is cereal, toast, orange juice. We have removed almost all fat. In the ’60s, we were much less overweight than we are today. Do you see a trend here? Remember, don’t demonize something. Make sure your breakfast contains some protein, carbohydrates and fat.

Success Is a Journey, Not a Destination

I don’t want to overload you with too much to think about. This should all be simple. So, for this month, I will let you chew on that (pun intended). In future articles, I will teach you to count your carbs without the Internet or a book or a degree in some new form of math. This should all be simple and part of your normal way of life. Work on these most basic principles, because if you do everything I listed in this first article, you probably wouldn’t need to read any more to start being successful at losing weight and maintaining a healthy body.

By Katie Miller

This past year, the United States hosted the 19th International AIDS Conference for the first time since 1990. Although the United States has established itself as a global leader in HIV/AIDS research and funding, it wasn’t until 2010 that the government lifted the entry ban on HIV positive people wishing to travel to America, thereby making the International AIDS Conference possible in this country. Before then, the United States stood out as one of only a handful of countries worldwide that barred people living with HIV from visiting or immigrating to the country.

ATLANTIC OCEAN (March 5, 2008) Hospital Corpsman 3rd Class Michael Ousley draws blood from a patient to test for Human Immuno-deficiency Virus (HIV) during a physical health assessment aboard the aircraft carrier USS Theodore Roosevelt (CVN 71). Theodore Roosevelt is conducting carrier qualifications. U.S. Navy photo by Mass Communication Specialist Seaman Andrew Skipworth

However, the U.S. military continues its own form of a travel ban. Military policy prohibits HIV-positive service members from being stationed outside the United States. But on Aug. 13 the Pentagon quietly released a revision to the Department of the Navy policy, which now allows HIV-positive Sailors to be stationed at U.S. military installations outside of the country and on select large ship platforms. The policy change, listed under Secretary of the Navy Instruction (SECNAVINST) 5300.30E, is intended to “reflect current knowledge” of HIV and marks the biggest change in military HIV policy since the late 1980s when mass testing for HIV went into effect. Though the update removes logistical barriers to service, it does nothing to dissolve the space for discrimination which falls under commanders’ discretion. As long as the policy allows good Soldiers, Sailors, Airmen, and Marines to be subjected to the prejudices of their superiors, our mission of equality in the military will be unaccomplished

An Overview of U.S. Military HIV Policies
Although each branch of service maintains its own policies relating to HIV-positive people, the services have several major commonalities. First, all service members are tested for HIV every two years at a minimum, when given overseas assignments and when reservists transition to active duty.

The second commonality concerns enlistment; people with HIV are not eligible for general enlistment or enrollment in officer accession programs. The medical evaluation mandates all potential enlistees be physically and psychologically equipped to survive battlefield conditions. Unsurprisingly, those dependent on prescription medication are unqualified for service, as the military cannot guarantee access to medications in all situations. HIV, which causes immune deficiency, poses an additional risk for potential enlistees because of mandatory live-virus vaccinations administered at basic training, which could be deadly for persons living with the virus. This section of the policy is uncontested.

The third addresses retention of personnel who become HIV positive while serving in the armed forces. When service members are notified of their status, they undergo a separate medical evaluation to determine if they are fit to continue serving. If they wish to remain in the service and the medical evaluations yield positive reviews, they are reassigned to posts near military medical facilities that retain an infectious disease doctor. For those serving overseas, this means relocating to a post within the continental United States. The entire duration of an HIV-positive member’s careers will be spent stateside for the purpose of visiting an infectious disease doctor every three to six months, so OCONUS assignments and deployments are prohibited.

Interestingly, cadets and midshipmen enrolled in officer accession programs are not eligible to continue serving, regardless of physical condition. However, if a cadet or officer candidate is prior service, a return to enlisted status is allowed if his or her contract has not yet ended.

Finally, the military issues “safe sex” orders to personnel with HIV, informing them that they will be criminally prosecuted if they fail to disclose their status to sexual partners or engage in unprotected sex. Similar laws are in effect in a majority of U.S. states, though ranging in extremity.

The Impact on Service Members with HIV
OutServe Magazine interviewed three active-duty, HIV-positive Soldiers and Sailors and an LGBT health professional about military HIV policies and their impact on service members. Names have been changed to protect the identities of the service members.

When asked about the quality of health care they received, the three service members were unanimously positive. Roger, an NCO and moderator of what was previously known as the OutServe HIV Working Group, said, “My care is better in the military than it would be in the civilian world. I don’t have to worry about the cost of medication. It’s mandatory for us to go see the doctor regularly.”

Alex, a junior officer in the Navy, concurred. He expressed considerable praise of the hospital personnel, who offered to reach out to his friends and family to help them learn more about HIV. “I had about seven friends who came in, sat down with someone from the infectious disease clinic, and talked with the staff. The hospital said to me, ‘Alex, if they’re important to you, it’s important that we educate them.’ It was phenomenal.”

But outside of the medical facilities, service members with HIV face a different challenge that military has yet to address: the possible prejudices of their units Because HIV-positive personnel take TDY every three to six months for medical testing, it’s imperative that command be aware of a service member’s ongoing needs.

Alex found himself rather fortunate in this regard. “It would be bad if someone gave me a negative fitness report. I’ve heard horror stories like that, but that hasn’t been my experience. I’ve been met with nothing but understanding from my unit. They’re like, ‘Everyone has medical issues. Take care of yourself. That’s what’s important.’”

Roger also felt lucky to be part of an accepting unit, but realized his experience is not universal. “It’s not going to be like that for everybody. It’s not going to be this good across the board.”

Matthew Rose, formerly of the National Coalition for LGBT Health and friend of OutServe-SLDN, describes military HIV policy as similar to “Don’t Ask, Don’t Tell.” He explained: “If you get the right commanding officer, your life can be good. Some people were out to their units and experienced no problems. But, if you get a commanding officer who doesn’t agree with your sexuality or has preconceived notions about HIV, there’s not much you can do about it.”

Since the disease still carries a significant level of stigma, the autonomy of the commander is the single biggest flaw in military HIV policy, as discrimination is sure to be as rampant in the military community as it is the civilian world. Lack of guidance means room for abuse.

Jesse found himself at the crux of this problem, in the middle of the space left open for discrimination. Since he was enlisted before attending a service academy and has yet to experience any symptoms of HIV, the policy would permit him to leave the academy at the end of the semester and continue serving in the enlisted ranks. However, his company officer immediately took action to separate him from not only the academy but the military altogether because he did not believe people with HIV should be allowed to continue their service Jesse filed a complaint with the inspector general, which only served to expedite the commander’s intent to separate Jesse.

As policy dictated, Jesse’s enlistment contract was eventually reinstated, and he continues to serve on active duty. But the process demonstrated how current policy left him vulnerable to his command leadership.

The current lack of non-discrimination policies for HIV-positive personnel makes it impossible for the military to abide by industry standard human resources principles that guide many organizations’ personnel policies. One of those standards, procedural justice rules, states that policies must be, among other things, consistent. It must apply equally across all people and time. The current policy does not apply across all people since commanders can make independent decisions regarding the assignments and missions for which HIV-positive service members are eligible. Another principle, interpersonal justice rules, maintains that all employees must be treated with respect. Again, with the lack of a non-discrimination policy in place, commanders have such a high level of individual discretion that can be, at times, disrespectful to those service members.

Policy Update: Navy Begins the March toward Equality
One of the issues most important to these servicemen was the ban on overseas assignments. At first glance, the regulation appears to be in the best interest of the service member’s health: because they must regularly visit one of the military’s hospitals with an infectious disease clinic, stateside assignments are closest in proximity and therefore ideal.

Rose argues against this logic. Referring to the U.S. Military HIV Research Program, “The military delivers HIV care in the most impoverished places on the planet, like Sub-Saharan Africa. Yet for some reason, they don’t believe they can deliver care for service members outside the United States. What’s more, in any major industrialized city you can find a [infectious disease] doctor or at least a place that can run labs and interpret results.”

Feasibility aside, the negative impacts of the overseas assignment ban on service members’ careers has become well known in recent years. Roger is quick to note the assignments available often offer little potential for moving up the ranks. When Alex’s commander was informed of his status, she took special care to ensure he would be placed in a position that would not prevent him from being promoted. She ordered, “Do not stick him in a billet that will end his career.”

The updated Navy HIV policy also points to this limitation as having “made this subset of personnel less competitive in achieving career milestones or warrior qualifications.” With HIV resembling more of a “chronic condition than anything else,” says Alex, the only performance barrier for service members with HIV is policy, not physical capability. The Navy and the interview participants agree: current military HIV policies have career-ending effects.
However, the other services have yet to similarly update their policies. Still, recognizing the difference in the nature of deployment for the other branches, the service members we interviewed understood the challenges. Roger stated bluntly, “I don’t believe we should be discussing combat zones. Whether you’re sitting behind a desk in Afghanistan or out doing patrols, everyone has the same risk of getting hurt. Medics don’t have time to consider if a person has HIV or not.”

But he does believe personnel could be managed better. “Take Kuwait, for example. It’s not a combat zone. But when the wars in Afghanistan and Iraq were full on, people were getting sent there, and they could have been used in better places, like in deployable units. All I would need is enough medication for the length of the tour, and I could have taken their place.”

Jesse expressed a similar sentiment. “In my MOS, I’d be doing the same thing in Kuwait that I would be doing in the United States. It wouldn’t change. I hope to stay in the military for a long time, and if my subordinates look at me and see that I don’t have any time overseas, they’re not going to respect me.”

OutServe-SLDN Executive Director, Allyson Robinson, applauds the Navy’s first step toward ending HIV-discrimination in the military and their efforts to remove barriers to career advancement for Sailor and Marines. But Robinson, an Army veteran and West Point graduate, also points out that the policy does nothing to ensure commanders do the right thing:

“The new policy is a modest improvement at best. The latitude it gives to individual commanders to deny these newly opened assignments to HIV-positive Sailors and Marines will likely prove problematic. Misinformation, stigma, and stereotypes should never be allowed to dictate military assignments. Until that kind of discrimination is prevented, policy changes like this may prove not to be worth any more than the paper they’re printed on.”

As President Barack Obama stated when the HIV travel ban was ended in 2009, “If we want to be the global leader in combating HIV/AIDS, we need to act like it.” And if America is going to lead the world in ending the pandemic, properly addressing it in its own armed forces would be a good starting point. Although many of the military’s health and personnel policies are satisfactory, further updates are obviously needed to reflect current knowledge of the virus and to remove the stigma which has pervaded policy formation in the past. With the release of the new policy, the Navy has raised the bar for equality in the military. But consistent with all tasks in the military, the only commendable performance is one which not only meets, but exceeds the standard.

Katie Miller can be contacted at KatieMiller@OutServe.org.

Next month we celebrate the first anniversary of the end of “Don’t Ask, Don’t Tell” (DADT). Amidst the joy, one group of patriots has nothing to celebrate. Transgender Americans remain unwanted warriors. Our military medical regulations pertaining to transgender individuals, written almost a half-century ago and essentially unchanged since, reflect the same narrow perspective that historically excluded other unwanted groups from military service. Qualified individuals, even those who may differ from the status quo, should be allowed to serve the country they love and contribute to the military’s mission.

As medicine is evolving in the 21st century, more emphasis is being placed on medical care based on evidence and implementing the best practices. Unfortunately, our current medical standards are not evidence-based; there is no medical support for a permanent ban on transgender individuals from ever being able to serve. To the contrary, forty years of evidence show that gender reassignment treatment provides positive benefits to individuals, improves their quality of life, and reduces or eliminates their gender dysphoria.

The American Psychiatric Association (APA) last week stated that being transgender does not impair one’s “judgment, stability, reliability, or general social or vocational capabilities…” This is something that ten allies, including Great Britain, Canada, Australia, and Israel, have already known for some time. Perhaps more importantly, they also recognize that, in military terms, transgender service members do not harm good order, discipline, and morale simply by being themselves.

The only three articles in the medical literature that address transsexuals in the US military in any manner were written during the Reagan era by then-serving medical officers. They are instructive because they show the true rationale behind the regulations: the real reasons for barring transsexuals were “similar to those excluding homosexuals (effects on unit morale).” George Brown, an Air Force psychiatrist, writing in 1989 was also as stark in his assessment of the situation:

[There] is a clear message that the military environment will not tolerate identified transsexuals in its ranks, irrespective of the quality of duty performance. [Emphasis added – Doesn’t this sound familiar?] Transsexualism continues to be viewed as a nonmedical defect requiring administrative separation, analogous to cases of homosexuality . . . in spite of ample medical evidence to the contrary. In 2012, nothing has changed in the military.

However the world is rapidly changing and it is time for the military to catch up. There is a worldwide recognized standard of care established by the World Professional Association for Transgender Health (WPATH) – one the military refuses to accept despite its acceptance in 2008 by the American Medical Association (AMA). (Dr. Brown, mentioned above, serves on the WPATH board of directors.) The recent statement by the APA condemning discrimination against transgender and gender non-conforming individuals specifically cited the military’s policy in justifying its stance.

Adding further momentum for change in the military’s medical standards is the reported forthcoming change to the APA’s Diagnostic and Statistics Manual (DSM). The fifth version will remove gender identity disorder and remove the stigma of mental illness from those who are gender non-conforming in a similar manner as it did in 1973 when it removed homosexuality as a mental disease. Gender dysphoria, the condition which is treated by gender reassignment, will remain. The APA, AMA, and WPATH also call for the proper access to treatment for gender dysphoria – now denied to military members and veterans. (The law barring the VA from providing gender reassignment surgery is a cynical basis for the military’s process of administratively discharging transgender members with gender dysphoria rather than medically discharging them.)

Admiral Mike Mullen, the former Chairman of the Joint Chiefs of Staff, stated repeal of DADT was a matter of integrity. The military’s use of medical regulations to bar transgender service, not for medical reasons but for unsubstantiated concerns about good order and morale, is no less an affront to the Core Values. It is time to admit that the medical standards completely barring all transgender service are nothing more than an echo of the same prejudices and pretextual arguments familiar from the DADT fight. The APA’s welcome step forward gives us an opportunity to review our standards, ensuring they are evidence-based, reflecting the best medical practices, supporting the health care our men and women in uniform deserve, and providing for the best fighting force our nation can produce.

Paula M. Neira was a Lieutenant, United States Navy / Naval Reserve from 1985-1991.

With summer finally upon us, it’s the season for Pride celebrations, barbecues and lazy days at the beach. We all know that it’s important to stay safe while having fun in the sun (wear those hats, T-shirts, and sunscreen, please!), and it is just as crucial to stay protected after dark as well. If you plan to be sexually active this summer, remember to protect yourself from human immunodeficiency virus (HIV) infection as well as other sexually transmitted infections (STIs).

HIV, the virus that causes AIDS, is transmitted through exchange of blood and body fluids. It can be transmitted through sex, by sharing needles during intravenous drug use or tattooing/piercing/bodywork, from mother to child during childbirth, and through transplant or transfusion of infected organs, tissue and blood products. It’s important to know your status. I recommend that men who have sex with men request an HIV test from their health care practitioner every six months. The sooner you find out that you are infected, the earlier you can seek treatment (which reduces your chance of getting sick and spreading the virus), and the more likely you are to protect your partners.

In the military community, unprotected sex is by far the most common risk factor for HIV transmission. An often-overlooked facilitator of infection is alcohol and drug use. Many of my patients have told me that they became infected because they did not use a condom, and that alcohol was a factor in that decision. So if you choose to drink, drink responsibly. It’s just like drinking and driving; if you’ve been drinking, then don’t have sex. If you plan to have sex, don’t get drunk.

It’s just like drinking and driving; if you’ve been drinking, then don’t have sex. If you plan to have sex, don’t get drunk.

Many service members are surprised to learn that HIV infection is a problem in the military. In fact, the military has a large population of HIV-positive service members and dependents who receive state-of-the-art HIV care at our military medical centers. While infection rates in the military remain lower than in the U.S. population at large, we do have new cases of HIV infection every year. Men who have sex with men are disproportionately affected. This article will focus on prevention for men who have sex with men, since lesbians are at much lower risk. Transgender service members may also be at risk, depending on their specific sexual practices.

According to statistics from the Armed Forces Health Surveillance Center, in 2010, there were 233 new cases of HIV in the active components of the Armed Forces. These cases included 90 new diagnoses of HIV in the active Army (0.20 per 1000 tested), 72 cases in the active Navy (0.30 per 1000 tested), 19 cases in the active Marine Corps (0.12 per 1000 tested), 46 cases in the active Air Force (0.17 per 1000 tested), and 6 cases in the Coast Guard (0.17 per 1000 tested). Nearly all of these newly diagnosed cases of HIV infection were in male service members. For comparison, the Centers for Disease Control (CDC) estimates that approximately 3 per 1000 Americans overall are HIV-infected. In the U.S. population at large, men who have sex with men account for 61 percent of new infections.

The most effective method to avoid becoming infected with HIV or any STI is not to have sex. I am not a fan of abstinence-only education (it does not work for high school students). Fortunately, there are some alternatives to complete celibacy. If you choose to have sex, there are a lot of ways you can share the bond of intimacy with your partner and keep your risk of infection low. Some low-risk alternatives include kissing, massage and body rubs, mutual masturbation, and frottage. Other sexual activities, including oral, anal, and vaginal intercourse, are higher risk. Remember, if you have genital or oral sores from injuries or other STIs such as herpes, your risk of HIV transmission is much higher.

Condoms are the single most effective method of preventing HIV infection if you are sexually active. The highest risk sexual activity is receptive anal intercourse (“bottoming”). Bottoming without a condom carries a fifty-times-greater risk for HIV transmission over oral sex. If you bottom without a condom, you are inviting HIV and other STIs into your body.

“Do not trust that your partners are being safe,” said Chief Petty Officer Will Means, who has been living with HIV infection for three years. “The only 100 percent surefire guarantee that you are protected is that you ensure condoms are used with each and every sexual partner you have. Never trust that your partner is negative, even if he says he is, or that he has been tested.”

Because oral sex can easily transmit STIs like gonorrhea, chlamydia, syphilis, and herpes, barrier protection (a condom or dental dam) is still recommended for oral intercourse. The risk of HIV transmission is lower with oral sex, but it still occurs and can be prevented through condom use. Condoms in a variety of exciting flavors are widely available online and in adult boutiques, and can make the use of a condom more enticing for oral sex.

If you forget to use a condom, if you are sexually assaulted, or if you experience a rare case of condom breakage, then it is important that you go to your hospital’s emergency department for evaluation, especially if you have been participating in a higher-risk activity like bottoming.

Military hospitals, just like civilian ones, offer post-exposure prophylaxis (PEP) for possible HIV exposures. This treatment consists of a combination of HIV medications, which are taken for 28 days. Although there may be side effects from the medications, they will substantially reduce your risk of HIV infection. You will be tested for HIV and again at 6 weeks, 3 months and 6 months after the exposure. When seeking PEP, time is of the essence—you must stop the virus during the few hours before it makes it into your T-cells, when life-long infection becomes established. Therefore this treatment is only offered within 72 hours of the exposure, and you should go to the hospital right away to have the best chance of preventing infection.

Recently there has been a lot of buzz about a new form of HIV prevention called pre-exposure prophylaxis, or PrEP. PrEP is targeted at individuals who are at high-risk for HIV infection, for example, gay men who have multiple partners, or long-term partners of HIV-positive individuals.

Despite possible drawbacks, military HIV specialists are likely to offer PrEP to selected patients now that as of July 16, the FDA approved the drug. Before offering this option, though, I would strongly counsel my patients about the possible risks (including drug side effects and the risk of acquiring other STIs if condoms are not used), and emphasize condom usage as a much cheaper, safer and possibly more effective preventive tool.

What if your best efforts at HIV prevention fail and you are facing a positive test result? Although receiving a diagnosis of HIV infection is a shock, it is certainly not the end of the road for your health, your love life, or your career. HIV infection is now a treatable, chronic condition, with life expectancies for HIV patients on treatment growing ever closer to life expectancies for HIV-negative persons. HIV-positive men and women can have a healthy love and sex life, as long as they take precautions to protect their partners.

For military members, command counseling for HIV-positive service members includes a direct order to notify sex partners of their HIV-positive status, and to use barrier precautions for vaginal, oral, and anal sex. HIV-positive service members may be subject to UCMJ action if they fail to protect their partners, fail to disclose their HIV status to partners, or if they contract other STIs (indicating failure to use protection). For this reason, I encourage HIV-positive service members to discuss this issue with their HIV specialist and find out their doctor’s philosophy about STIs and command notification. Some military HIV specialists think that the fear of UCMJ action might discourage service members from seeking care for STIs, and they therefore may not notify a service member’s command of an STI diagnosis unless a pattern of irresponsible behavior develops.

HIV-positive service members receive high-quality care in the military health system and continue to serve in a variety of career fields. Most service members who are diagnosed with HIV elect to remain on active duty, although they have the option of leaving service if they so choose. While they are considered non-deployable due to military regulations and international status-of-forces agreements, they have successful military careers. Still, the career limitations of being HIV-positive in the military can produce some unpleasant surprises.

Says Chief Means: “Since becoming HIV positive, I am no longer allowed to go to sea. It makes diversity in job assignment difficult to stay competitive for promotion. Don’t take the risk of being treated like an infection instead of a Soldier, Sailor, Airman, or Marine.”

By David Small

I’m 36 years old. I’m between a generation who were adults living through the 1980s AIDS crisis, who can count the number of friends they lost to the disease in the dozens, and a generation who is, by my counts—apathetic at the most, and nonchalant at best about safe sexual practices. The disappearance of fear in our youth over contracting HIV scares me.

And today I see the USA Today headline, “The AIDS epidemic: Beginning of the end?”

As a professional communicator, I’m appalled by editors who sensationalize a story down into a few words in a grabbing headline like this. Because one message I got from reading the complete story is that people, a lot of people, particularly in young minority groups, evermore are contracting the virus at astounding rates.

How can such a statistic contribute to such a headline?

While I applaud the fact that in general, society no longer treats HIV+ people as pariahs, I think our collective progress toward understanding that you can’t contract HIV from simple contact has provided a slippery slope fueled by the media stating it is no longer a death sentence. That slippery slope seems to have spawned an entire generation of people who don’t seem to be taking precautions.

Here are some pertinent excerpts from the article that are completely buried under scientific hullabaloo that doctors can now practically cure the disease. You can practically cure it? Well, hell… if you can practically cure it anyway, then why do I have to wear a jimmy hat? That’s what some kid out there is thinking now because of this article.

• In communities with high infection rates, people can be at risk even without being promiscuous, simply because the virus is found at such high rates within their social network, says Justin Goforth, a registered nurse at Whitman Walker Health in Washington. In these communities, staying HIV-free requires “perfection,” Goforth says, or at least 100 percent condom use.
• Young gay men — who don’t remember when AIDS was a universal death sentence — are the only group in which the rate of new infections is increasing, largely due to an “alarming” growth in the disease among gay black youths. The HIV infection rate climbed 48 percent among young gay black men from 2003 to 2009, according to the CDC.
• Many young people are unaware or in denial of the dangers of unprotected sex, which HIV patient Kevin Swinton compares to “Russian roulette.” Other young people are fatalistic, he says. Convinced that they’ll eventually contract HIV anyway, they decide to have fun while they can, says Swinton, 36, of Silver Spring, Md. “I knew the risk was out there,” Swinton says. “D.C. is small enough that eventually, everybody sleeps with everybody.”

The USA Today article blames such attitudes by our youth today on lack of sex education and lack of access to health care. That may be spot on, particularly for those who are poor and disenfranchised. But a third factor ought to be with the media and medical community who recite low statistics for certain activities.

In a conversation with a dear friend, he told me he practiced unsafe sex with multiple partners he knew were HIV+. He stated that because he was not the receptive partner, and that his partners were “undetectable,” he was willing to accept the reduced risk. I wanted to vomit. He’s a decade younger than I am and fairly new to being gay. He’s not poor. He has access to military health care. He is well educated. And other than the normal growing-up-Christian-and-rejecting-it-upon-coming-out stuff, he isn’t disenfranchised. How on earth did he get this nonchalant attitude?

My view certainly isn’t all encompassing to all Millennials. I know plenty in the younger generations who do practice safe sex. And one anecdote does not make a trend. But I’m personally seeing this more and more. And I just have to ask, “why?”

Here’s much better coverage of the issue than USA Today… and it’s from 2008! The title, “Circumcised Gay Tops ‘Less Likely To Contract HIV’.”

But instead of jetting into coverage of the Sydney Morning Herald’s story, the article in this Australian gay men’s magazine asks if this kind of research sends the wrong message. Of those who responded, 60 percent said yes – it’s another dangerous excuse for having unsafe sex. The other 40 percent said no, the sensible safe guys won’t stop using condoms.

Don’t get me wrong, I am absolutely thrilled for the scientific breakthroughs made in the last decade. One of my dearest friends on the planet has been living with HIV for more than 20 years and is a long-term non-progressor. For the first 18 years he had it, he wasn’t on any meds and today is a part of the National Institute of Health study to find out why he is still alive. He also has to live with what comes with being HIV+, like his fear when his T-cells, despite being on meds now, dropped recently to near AIDS levels. It is scary to face your own mortality. Today, he is healthy, in fantastic spirits, and will live a long and fruitful life. He will die at an old age of happiness.

I’ll close with the caption under a rather nice photo of a muscular bubble butt from this Australian article, “If you wanna tap it, you should wrap it.”

Perhaps if editors published more photos like that and less sensational headlines, people would read further for the full message—there is still risk, take precautions.

As I transitioned, health care coverage has truly been a trip through the looking glass. When I started the process, I worked for a company which had health benefits that extended to same sex partners.  It also covered many transition related expenses such as labs for hormone levels, Gender Identity Disorder (GID) related doctor and therapist visits, surgeries related to a sex change, and hormone therapy.

However, my luck ran out at about the same time I fully transitioned.  The next company I went to did not offer any benefits to same sex partners.  It will not cover any GID related medical coverage.  This has led to some very odd work-arounds to ensure my family has benefits.  My driver’s license, passport, DEERS information, CAC card, and company records say I am female.  All of my wife’s documentation says she is female.  However, I had to prove my marriage is NOT same-sex by providing a joint 1040 form and my Florida marriage license to the benefits department. At my doctor’s office, they are re-coding my records as female so they can use non-GID related codes for my appointments, labs, and prescriptions for hormones.

In other words, I have to be legally both male and female at any given time, depending on who is looking at that moment.

The transgender community has suffered disproportionately from several issues including unemployment, under employment, lower pay when equally qualified, higher HIV infection rates, lack of access to health insurance, and discrimination by health care providers.  The landmark study by National Center for Transgender Equality (NCTE) surveyed a remarkable 6,000+ transgender individuals to assess the state of transgender people in the US, and devotes a chapter to health care issues.

• Injustice at Every Turn: A Report on the National Transgender Discrimination Survey

President Obama’s landmark Affordable Care Act (ACA) addresses all of these issues.  The NCTE has put together an excellent briefing describing the benefits of the ACA for transgender individuals.

• Health Care Rights and Transgender People

The downside is that state provided health care pools are unlikely to cover most or all of the expenses usually associated with transition.  This includes counseling or therapy for Gender Identity Disorder (GID), Hormone Replacement Therapy (HRT), lab tests as a part of HRT, Facial Feminization Surgery (FFS), of Sex Reassignment Surgery (SRS).  It might seem counterintuitive to discover insurance policy writers cannot discriminate against transgender people, yet don’t provide any services directly related to being trans; the language of the ACA only applies to the issuance of policies, not what they cover.  In other words, it is not discriminatory if no one has Gender Identity Disorder (GID) related issues covered.
According the annual Human Rights Campaign (HRC) Corporate Equality Index (CEI) survey, an increasing number of corporate health policies have been covering some or sometimes even all of these treatments.  This type of coverage tends to be with higher-end, comprehensive policies. While neither side in the debate over health care agrees how many of these higher-end policies will be dropped, there is agreement that some companies will.  The Congressional Budget Office assessed how many companies were expected to drop coverage as part of their estimates of the costs associated with the ACA.

Without the ability to produce my own hormones anymore I am susceptible to a host of medical issues if I do not have access to HRT and lab work.  For others who need psychological support, access to care can be a matter of life and death.  If I had not had access to a therapist with experience in gender dysphorias, I doubt the outcome of my transition would have been this smooth.  The recent National Center for Transgender Equality survey found that 41% of transgender people have attempted suicide.  An unknown number succeed.  Based on both these criteria, coverage for GID related issues is a legitimate need.

The practical upshot is that getting basic health care will be easier, but policies covering transition related issues will likely become less common in the near future. For those already in the private sector, some of this risk can be mitigated by how your doctor or therapist codes their treatments and prescriptions for insurance purposes. Some doctors may agree to this, other may not wish to take the chance. For current service members the best way to ensure you have ongoing access to GID related care is to make sure references to your GID issues are already in your medical records before you leave.

Since June 2011 it has been official policy that the Veteran’s Administration can provide mental health counseling, hormones, and pre and post-operative care to transgender veterans. Genital surgery is still forbidden. Obtaining these non-surgical treatments after leaving the military may be easier when it has already been noted in your medical records as a pre-existing condition.

• VA Policy on Treatment and Care of Transgender and Intersex Veterans

VA health benefits are available to many people even if they did not serve 20 years or suffer a service related disability.  Anyone who has served in a combat theater in the past five years is likely to be eligible.  Eligibility is determined when an application is submitted.

• Am I Eligible for VA Health Benefits?
• Application for VA Health Benefits

The transgender community will disproportionately benefit from the ACA due to existing discrimination in employment and health care, as well as a general lack of legal protections.  However, the ACA leaves out guarantees of coverage for GID related issues.  The ACA is treating the symptoms of GID, but not the cause.  Failure to address  the underlying issue has a demonstrably high mortality rate.  I am lucky; I have been able to keep my benefits through some legal loopholes without VA assistance.  Most other trans people are not so lucky.  This gap in coverage needs to be fixed.

Below is a Facebook conversation sparked by the USA Today article “Federal Policy Blocks Many Gay Men from Blood Donation.” The conversation debates the decades-old rule banning men who have sex with men to donate blood products to the nation’s supplies. The conversation begs the question whether the ban is a form of discrimination, a form of sound risk management, or a lazy federal regulation that could be improved through better testing of the blood supply.

B:  “Did you know that men who have sex with other men are banned by the FDA from donating blood? Have anal sex just once, and you’re banned for life. Seems we still have a long way to go on the equality front…”

S:  “That’s been around since the early 80s. Same rule for people with tattoos. Higher risk populations shouldn’t give blood if the blood people won’t properly screen it.”

B:  “Higher risk? I’m in a gay, monogamous relationship and am tested for HIV every six months. My 21-year-old heterosexual nephew has six kids by five different women and has never been tested for STDs. He is the most promiscuous person I know. He’s allowed to donate, and I’m not. I’d say he’s at a much higher risk of HIV than I am, wouldn’t you?”

S:  “Two people do not make a valid statistic. I would argue that in general, gay males still have a higher HIV rate. By my argument, DC residents with such a high percentage shouldn’t donate either. Sound logic applies. We ought to be arguing for the blood industry to step up to testing vice hollering that not all gays are whores.”

B:  “Even if we did have a higher risk, it’s still discrimination.”

S:  “A discriminator used to factor out statistically valid risk groups does not make it discriminatory! Don’t be such the offended victim.”

B:  “They mentioned in the article that gay men with HIV weren’t likely to donate to begin with. And of the ones that do, the tests only fail to detect HIV in one in a million infections! Your “statically valid” risk is so infinitesimal, it’s not worthy of being used to justify discrimination.”

How do you see this federal policy? Is it discriminatory? Is it a medically sound practice? What could the federal government do better to still keep the blood supply safe while opening the aperture of those who are able to give?

What about an interim solution? Since the military has compulsory HIV screening and now that gays can be out and serve, should military men who have sex with men be exempted? What are your thoughts?

Of note, the U.K. Department of Heath softened their stance last year on accepting donations from gay men, so long as homosexuals have not had sex with another man within the past year. This policy change ended Britain’s blanket ban on gay and bisexual donors that had been on the books for 30 years.

By David Small, Associate Editor

Ten years ago, Today Show anchor, Katie Couric, had a colonoscopy on live television to promote preventive screenings after her husband died from colon cancer in 1998. It was uncomfortable to watch, but created a national conversation leading to an increase in the number of colonoscopies.

Today, gay service members would benefit from another live viewing of a different sort to help promote preventive health care among their community ­— an anal pap smear. It sounds uncomfortable, especially when it’s described as a bottlebrush inserted into the rectum. But it isn’t bad.

Most women receive a cervical pap smear to check for genital human papillomavirus (HPV). According to the Center for Disease Control, it is the most common sexually transmitted infection with more than 40 types, which the body can sometimes clear naturally. But on occasion, HPV will lead to cancer.

Like other sexually transmitted infections, HPV can also affect the mouth, throat or anus. Most people who have HPV do not know they have it. The CDC reports 10 percent of heterosexuals have HPV in the rectal region. Most recently, former Charlie’s Angel Farrah Fawcett died of anal cancer. “People using these areas as sexual organs should routinely get checked, even if they are not the receiving partners,” said Dr. Timothy Price, a civilian primary care physician at Price Medical in Washington, D.C.

While medical care for gays and lesbians is primarily the same as heterosexuals, there are some differences, such as the need to check for HPV more regularly. Just as doctors would treat a woman of childbearing age differently than one who is older, there are risks for certain things when treating LGBT members that ought to be factored into a clinician’s decision-making process.

But in today’s military, medical providers are not widely seeking the right information to assess an LGBT person’s health, and gay patients are not keen to volunteer the right kind of information to their military health care providers. These claims are according to an innovative, new study that assesses the public health impact of “Don’t Ask, Don’t Tell” (DADT), “How Military Health Care Just ‘Got Better’: Evaluating the Public Health Impact of DADT,” by OutServe member ENS Jonathan R. Barry.

DADT Caused Lost Health Care Opportunities

Ensign Barry, a third-year medical student on a Navy health professions scholarship at the University of Tennessee, seeks a military career in preventive medicine. More than a thousand LGBT service members responded to his survey. The questions assessed LGBT members’ knowledge, attitudes, health beliefs, behaviors and actions during and after DADT.

Respondents were equally spread among the services and were primarily active duty. Nearly 70 percent were enlisted, and 80 percent of respondents were male.

One of its most telling data points regards service members who wanted care for a particular LGBT issue through a military health care provider, but didn’t seek it because of DADT fears.

Nearly half of the respondents wanted help for a mental health issue related to their LGBT status. Furthermore, 30 percent desired help for a same-sex domestic issue, 26 percent wanted an STD test, 27 percent needed psychiatric care, and 31 percent sought other LGBT-related health care.

Unfortunately, none of these respondents sought help from a military provider. Small percentages of each did seek care external to the military medical community; however, most sought no help at all.

“The difference between the percentage of LGBT members who wanted health care and the percentage who actually received health care ranged between 15 and 30 percent, depending on the particular issue, and this can best be thought of as lost health care opportunities,” said ENS Barry. “DADT was largely viewed as a patient barrier, and this barrier was especially pronounced regarding mental health issues. Given today’s emphasis on mental health and well-being, I think it’s interesting there was so much undelivered care because of the sheer fear of DADT.”

The study also looked at patient behavior after DADT’s repeal, concluding that a residual effect from the defunct policy is still preventing patients from adequately disclosing information about their sexual practices.

“For most of the lifetime of DADT, there was a lot of ambiguity as to whether doctor-patient information was protected until it was explicitly outlined in a March 2010 DoD directive,” Ensign Barry said. “But even then, only one in five respondents knew about this highly significant policy change regarding DADT.”

It should be noted that there is no data comparing the rate at which heterosexuals sought similar health care. These numbers do not construe any conclusions about the rate at which gays and lesbians needed treatment for various issues compared to heterosexuals.

No Judgment

To combat these disconcerting claims, OutServe Magazine sought the advice of Dr. Price, an expert with 20 years of experience treating the gay community. He started Price Medical, a 2,500-patient, primarily gay medical practice in 1997 with the goal of being a comfortable place for gay people to seek medical care, knowing they won’t be judged.

“People need to be honest with their medical providers,” he said, noting his patients don’t have to explain how they end up in compromising situations. “From a medical provider’s point of view, the way you serve the population is by being open and non-judgmental about the person you’re seeing. That begins by accepting all types of people and behaviors as equal or valid options. We can’t have preconceived ideas about answers to questions.”

Ensign Barry agrees, “You don’t have to go to your doctor waving a rainbow flag. You don’t even have to necessarily tell your provider your sexual orientation. But it is important to clearly talk about who you have sex with — be them men, women or both — and how.”

To help foster disclosure, Dr. Price suggests providers give options and dig deeper to get a better picture of a patient’s sexual history.

“It’s a skill that has to be learned,” he said. “In medical training, people are not trained well to take sexual histories. Providers have to have practice, just like any other skill in medicine.”

According to the study, most gays and lesbians were unsure about whether doctor-patient privilege applied to disclosing their sexual orientation during DADT. Therefore the vast majority of military doctors have not had much experience culling sexual histories specifically from serving gays and lesbians. Without regular practice, as Dr. Price said, these doctors are wholly unprepared at this point to adequately treat this population.

One simple example Dr. Price gave is the standard form question, married or single? With respect to gays and lesbians, this question reveals nothing. A man could be married to a woman, but have had sex with men. Conversely, if a lesbian answers “single,” but is in a committed relationship with a woman, she probably doesn’t need birth control, said Dr. Price.

“[Not getting a correct sexual history] can lead people down the wrong path regarding health recommendations,” he said.

Just asking if a person is gay or straight won’t work because some men who self-identify as straight may still have sex with men, hence the clinical term, “men who have sex with men.”

However, some areas of the military only rely on a computer questionnaire to delve into a person’s history. Without a computer “red-flagging” a medical issue, a service member may not even have the opportunity to see a doctor for an annual checkup to discuss these points. This puts the complete onus on the individual to be forthright to computer-generated questions.

“The most you are required to do is show up for an appointment with an Airman who reviews your documents and asks if you have any questions,” said Air Force Capt Eddy Sweeney. “It’s ridiculous. This is something that absolutely needs to be addressed.”

Getting Tested

U.S. Air Force photo by Senior Airman Katie Gieratz/Released

“Often I hear, ‘we’ve been together for 15 years,’ but that might not mean monogamously,” said Dr. Price. “The next question you have to ask is if a relationship is monogamous. And it isn’t so much the number of sex partners you have, but what you’re doing with them.”

While he said each person is different, if a person is engages in routine safer sex using condoms, he suggests STD and HIV testing every 6 – 12 months. Those engaged in riskier behavior should test at least every six months.

“If a person is monogamous, then most clinicians would say the patient is at low-to-no risk for STDs, and screening doesn’t need to be as extensive as those who are not monogamous,” said Dr. Price.

While the military regularly tests for HIV, typically, the calendar prompts the test and feeds a person’s deployment readiness vice routinely reacting to a person’s risk factors.

“Depending on the sophistication of the caregiver, service members might need to volunteer that they are fearful of having been exposed, otherwise non-specific symptoms may not get properly evaluated,” said Dr. Price.

A significant majority of patients having been infected with HIV will experience some kind of symptoms 4-6 weeks after exposure, he said. The symptoms present in a non-specific manner like the flu: fever, malaise, sweats, rash; and these could be mild to significant.

If a person engages in unprotected sex, then these symptoms could be a viral syndrome related to newly-acquired HIV. Doctors not routinely involved in identifying HIV patients may not recognize these symptoms, and patients not forthright disclosing their sexual history may be at risk for missing such a diagnosis, he said.

What Else?

Dr. Price recommended other preventive health measures for the LGBT community as well.

While not conclusive, some studies suggest that because of a hormonal change that occurs with birth control and pregnancy, lesbians not on birth control or prone to pregnancy tend to be at a higher rate of risk for breast cancer. Dr. Price suggests “screening and self-examination monthly needs to be more regular for lesbians.”

Lesbians, like anybody else, can also transmit other infections through skin-to-skin touching and fluid exchange.

For men who have sex with men, they should be properly vaccinated against Hepatitis A and B. “A records review of most military people shows that the military generally vaccinates against Hep A, but not Hep B,” said Dr. Price.

Regarding mental health, there can be a higher level of anxiety and depression disorders for LGBT people who are at the point of coming to terms with their sexuality, and who have repressed it within the military construct. “There is a stigma attached to people in the military if they admit any kind of emotional weakness,” he said.

Dr. Price recommends assessing a person’s mental health by using an open ended question such as “Tell me about your mood,” which puts the onus on the person to speak, versus going down a checklist of yes/no questions prompted by a computer screen, to which some military providers have resorted.

If military members have concerns about losing their security clearance, they should research the appropriate regulations. Going to mental health does not necessitate the suspension or revocation of a security clearance, and is generally situation-dependent.

The Military’s Response

As the era of DADT fades into history, it is expected that lost health care will diminish. However, the ability of providing specialized health care for LGBT people in the military is currently sparse.

After the Comprehensive Review Working Group issued its implementation plan for the repeal of DADT, no DoD medical policy changed.

According to a memo to the services from Clifford Stanley, the Undersecretary of Defense, “There will be no changes to existing medical policies. The Surgeons General of the military departments have determined that repeal of DADT does not affect the military readiness of the force and that changes to medical policies are not necessary.”

Spokeswoman for DoD, Cynthia Smith, said, “Medical personnel are educated and trained in dealing with the psychological and physiological aspects of gay and lesbian medical concerns, and that includes members of the military medical department.”

According to the Air Force Surgeon General, instruction on obtaining a comprehensive sexual history, and the professional and sensitive approach to doing so, exists within the core curriculum of national medical and nursing schools, to include the military medical school. However, among all the services, only the Navy and Marine Corps Public Health Center has any established resource for practitioners that specifically address the sexual health of LGBT troops.

“The Navy and Marine Corps Public Health Center maintains guidance for clinicians and healthcare providers on how to best address the medical concerns of the lesbian, gay, bisexual and transgender community,” said Navy Medicine spokesman CAPT Cappy Surette. The Navy’s information is publicly available on their sexual health and responsibilities resources webpage found at: http://www.nmcphc.med.navy.mil/Healthy_Living/Sexual_Health/msm.aspx.

The Army Surgeon General’s spokeswoman responded that the Army uses a broad-brush approach to comprehensive, holistic care for all aspects of any soldiers’ health, not specifically providing resources to treat LGBT members.

The Air Force Surgeon General believes that as their caregivers become more attuned to treating LGBT troops, that the specialized skills necessary to do so will increase. Having said that, there is no program, policy or effort to jump start increasing these skills for clinicians who likely haven’t had to deal with LGBT patients since school.

“Subsequent to medical training, the proficiency with which military providers and nurses elicit an LGBT person’s sexual history and deal with LGBT clinical issues is a function of both previous education and the nature and frequency of LGBT patient encounters. As openly practicing LGBT personnel in the military increase, our healthcare providers’ art in extracting historical detail, and LGBT patients’ comfort in revealing those details, will only improve,” said a spokesman for the Air Force Surgeon General.

These statements drive home the importance of LGBT patients being open and honest with their caregivers regarding their sexual history, putting the onus on the service member to be an active participant in their own health care.

“Patient privacy is a top priority for our providers,” said Captain Surette. “As such, self-disclosure by patients of any medical conditions or personal factors they feel could impact their medical care is imperative to ensure the provider is able to address their specific needs.”

Despite the services’ responses and lack of change to policy, there has been no department-wide effort made to enhance skills necessary to treat LGBT issues by military medical practitioners since repeal.

Recommendations

“By and large, most of the health care that gays and lesbians need is no different than the general population,” said Dr. Price. “Where it differs the most is when it comes to sex. What is it about this person’s sex life that either predisposes them or protects them from certain illnesses?”

Dr. Price encourages service members to realize that clinicians can’t read their minds; without disclosure, providers may base their judgment on possibly false assumptions. “They can’t make the proper recommendations if they don’t know the facts.”

Ensign Barry’s study concludes with specific directions to better foster an environment where doctors know the right questions to ask and patients are comfortable enough to answer those questions, thereby disclosing appropriate facts.

First, “efforts should be taken to not only collect data on the types and costs of lost health care, but also to educate LGBT members so that additional future health care can be delivered, helping to correct the discrepancies identified in this research,” he wrote.

With his data showing service members are not likely to disclose pertinent issues, Ensign Barry suggests additional resources be produced to inform and educate LGBT service members on how to be an active partner in their health care. “Resources could include what type of health information an LGBT service member should share with a military health care provider, why it should be shared, and how a provider will deliver personalized care based on that information,” states his study.

Lastly, Ensign Barry recommends further research in this area to examine, from both a patient and provider perspective, why such low percentages of providers ask medically relevant questions. This research should seek to enhance medical training and practice guidelines for military health care providers concerning LGBT health issues.

“In any patient pool, specific populations like LGBT members need not be disenfranchised from the system. This current data illustrates that there is a lot more work to do to get patients to be more open with their health care providers and health care providers to retool how they’ve been trained to better assist LGBT health issues,” Ensign Barry said.

“This is going to be a big change for the military,” said Dr. Price.

Ensign Barry’s research, “How Military Health Care Just ‘Got Better’: Evaluating the Public Health Impact of DADT,” was recently submitted to the journal of Alpha Omega Alpha, the national medical honor society, for an essay competition, and is not yet publicly available.