OFFICE OF THE DEPUTY SECRETARY OF DEFENSE 1010 DEFENSE PENTAGON WASHINGTON , DC 20301-1010 March 12, 2019 MEMORANDUM FOR CHIEF MANAGEMENT OFFICER OF THE DEPARTMENT OF DEFENSE SECRETARIES OF THE MILITARY DEPARTMENTS CHAIRMAN OF THE JOINT CHIEFS OF STAFF UNDER SECRET ARIES OF DEFENSE CHIEF OF THE NATIONAL GUARD BUREAU GENERAL COUNSEL OF THE DEPARTMENT OF DEFENSE DIRECTOR OF COST ASSESSMENT AND PROGRAM EVALUATION INSPECTOR GENERAL OF THE DEPARTMENT OF DEFENSE DIRECTOR OF OPERATIONAL TEST AND EVALUATION CHIEF INFORMATION OFFICER OF THE DEPARTMENT OF DEFENSE ASSISTANT SECRETARY OF DEFENSE FOR LEGISLATIVE AFFAIRS ASSISTANT TO THE SECRETARY OF DEFENSE FOR PUBLIC AFFAIRS DIRECTOR OF NET ASSESSMENT DIRECTORS OF THE DEFENSE AGENCIES DIRECTORS OF THE DOD FIELD ACTIVITIES SUBJECT: Directive-type Memorandum (DTM)-19-004 - Military Service by Transgender Persons and Persons with Gender Dysphoria References: See Attachment 1. Purpose. This DTM: • Implements the policy in the February 22, 2018 Secretary of Defense Memorandum and the February 2018 DoD Report and Recommendations on Military Service by Transgender Persons, assigns responsibilities, and prescribes procedures regarding the standards for accession, retention, separation, in-service transition, and medical care for Service members and applicants with gender dysphoria, as applicable. • Approves updates to the separation processing guidance in DoD Instructions (DoDis) 1332.14 and 1332.30. These DoDis will be administratively changed in accordance with Attachment 4 of this DIM; the changes will be effective 30 days after publication of this DTM. • ls effective April 12, 2019. This DTM will be incorporated into DoDis 1300.28, 1332.14, 1332.30, and 6130.03, and supersedes any contradictory DTM-19-004, March 12, 2019 guidance in those publications. This DIM will expire effective March 12, 2020. Applicability. This DTM applies to OSD, the Military Departments (including the Coast Guard at all times, including when it is a Service in the Department of Homeland Security by agreement with that Department), the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the Department of Defense, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD. Definitions. See Glossary. Policy. It is DoD policy that: • Service in the Military Services is open to all persons who can meet the high standards for military service and readiness without special accommodations. • All Service members and applicants for accession to the Military Services must be treated with dignity and respect. No person, solely on the basis of his or her gender identity, will be: o Denied accession into the Military Services; o Involuntarily separated or discharged from the Military Services; o Denied reenlistment or continuation of service in the Military Services; or o • Subjected to adverse action or mistreatment. Except where a provision of policy has granted an exception, transgender Service members or applicants for accession to the Military Services must be subject to the same standards as all other persons. o When a standard, requirement, or policy depends on whether the individual is a male or a female (e.g., medical fitness for duty; physical fitness and body fat standards; berthing, bathroom, and shower facilities; and uniform and grooming standards), all persons will be subject to the standard, requirement, or policy associated with their biological sex. o Transgender persons may seek waivers or exceptions to these or any other standards, requirements, or policies on the same terms as any other person. • Service members who access in their preferred gender or received a diagnosis of gender dysphoria from, or had such diagnosis confirmed by, a military 2 DTM-19-004, March 12, 2019 medical provider before the effective date of this DTM will be allowed to continue serving in the military pursuant to the policies and procedures in effect before the effective date of this DTM. • Accession and retention standards for gender dysphoria and the treatment of gender dysphoria will be aligned with analogous conditions and treatments, including stability periods and surgical procedures. Responsibilities. See Attachment 2. Procedures. See Attachment 3. Information Collections. The requests for medical reports and history referred to in Paragraph 2.b. of Attachment 3 do not require licensing with a report control symbol in accordance with Paragraph l.b.(13) in Enclosure 3 of Volume 1 ofDoD Manual 8910.01. Releasability. Cleared for public release. Available on the DoD Issuances Website at https://www.esd.whs.mil/DDI. ff&lJ t/,Lf- David L. Norquist Performing the Duties of the Deputy Secretary of Defense Attachments: As stated cc: Secretary of Homeland Security Commandant, U.S. Coast Guard 3 DTM-19-004, March 12, 2019 ATTACHMENT 1 REFERENCES Assistant Secretary of Defense for Health Affairs Memorandum, " Guidance for Treatment of Gender Dysphoria for Active and Reserve Component Service Members," July 29, 2016 Commandant Instruction Ml 850.2 (series), "Physical Disability Evaluation System," May 19, 2006 Department of Defense, "Department of Defense Report and Recommendations on Military Service by Transgender Persons," February 2018 Department of Defense, "Transgender Service in the U .S. Military Implementation Handbook," September 30, 2016 Directive-type Memorandum 16-005, " Military Service ofTransgender Service Members," June 30, 2016 DoD 6025.18-R, " DoD Health Information Privacy Regulation," January 24, 2003 DoD Instruction 5400.11 , "DoD Privacy and Civil Liberties Programs," January 29, 2019 DoD Instruction 1300.28, " In-Service Transition for Transgender Service Members," June 30, 2016 DoD Instruction 1332.14, "Enlisted Administrative Separations," January 27, 2014 , as amended DoD Instruction 1332.18, "Disability Evaluation System (DES)," August 5, 2014, as amended DoD Instruction 1332.30, "Commissioned Officer Administrative Separations," May 11 , 2018 DoD Instruction 1332.45, "Retention Determinations For Non-Deployable Service Members," July 30, 2018 DoD Instruction 6130.03 , "Medical Standards for Appointment, Enlistment, or Induction in the Military Services," May 6, 2018 DoD Instruction 6490.10, "Continuity of Behavioral Health Care for Transferring and Transitioning Service Members," March 26, 2012, as amended DoD Manual 8910.01, Volume 1, "DoD Information Collections Manual: Procedures for DoD Internal Information Collections," June 30, 2014, as amended Secretary of Defense Memorandum, "Military Service by Transgender Individuals," February 22, 2018 United States Code, Title 10, Section 1074 United States Department of Defense, "Transgender Service in the U.S. Military Implementation Handbook," September 30, 2016 4 Attachment 1 DTM-19-004, March 12, 2019 ATTACHMENT 2 RESPONSIBILITIES 1. UNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS (USD(P&R)). The USD(P&R): a. Will revise DoDis 1300.28, 1332.14, 1332.30, and 6130.03, consistent with this DTM. Unless otherwise specified in this DTM, if these issuances are inconsistent with this DTM, this DTM will govern. b. Will revise the U.S. DoD Transgender Service in the U.S. Military Implementation Handbook, consistent with this DTM. c. Will disseminate the revised handbook to all Military Departments and the United States Coast Guard (USCG). 2. ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS. Under the authority, direction, and control of the USD(P&R), the Assistant Secretary of Defense for Health Affairs will issue medical guidance as appropriate. 3. SECRETARIES OF THE MILITARY DEPARTMENTS. The Secretaries of the Military Departments: a. As necessary and appropriate, will develop implementing guidance for their respective Departments and Services consistent with the policies and procedures in this DTM. b. May grant waivers in accordance with Paragraph 3 in Attachment 3 of this DTM, in whole or in part, in individual cases. Waiver authority permitting an applicant or Service member, who is not exempt pursuant to this policy, to serve in his or her preferred gender may be delegated, in writing, no lower than the Military Service Personnel Chiefs. All other waiver authority remains with the Service-designated waiver authority. 4. COMMANDANT. USCG. The Commandant, USCG: a. As necessary and appropriate, will develop implementing guidance for the USCG consistent with the policies and procedures in this DTM. b. May grant waivers in accordance with Paragraph 3 in Attachment 3 of this DTM, in whole or in part, in individual cases. Waiver authority permitting an applicant or Service member, who is not exempt pursuant to this policy, to serve in his or her preferred gender may 5 Attachment 2 DTM-19-004, March 12, 2019 not be delegated lower than the Assistant Commandant for Human Resources. All other waiver authority remains with the Service-designated waiver authority. 6 Attachment 2 DTM-19-004, March 12, 2019 ATTACHMENT 3 PROCEDURES 1. SECTION I: EXEMPT INDIVIDUALS. a. Applicability. Individuals are exempt from Paragraph 2 of this attachment if they, before the effective date of this DTM: (1) Entered into a contract for enlistment into the Military Services using DD Form 4, "Enlistment/Reenlistment Document Armed Forces of the United States," available on the DoD Forms Management Program website at https://www.esd.whs.mil/Directives/forms/, or an equivalent, or were selected for entrance into an officer commissioning program through a selection board or similar process; and (2) Either: (a) Were medically qualified for Military Service or selected for entrance into an officer commissioning program in their preferred gender in accordance with DTM-16005; or (b) As a Service member, received a diagnosis of gender dysphoria from, or had such diagnosis confirmed, by a military medical provider. b. Appointment, Enlistment, or Induction into the Military Services. Individuals who are exempt will be accessed or commissioned based on the following medical standards, provided they are medically qualified in all other respects in accordance with DoDI 6130.03: (1) A history of gender dysphoria is disqualifying, unless, as certified by a licensed mental health provider, the applicant has been stable without clinically significant distress or impairment in social, occupational, or other important areas of functioning for 18 months. (2) A history of medical treatment associated with gender transition is disqualifying, unless, as certified by a licensed medical provider: (a) The applicant has completed all medical treatment associated with the applicant' s gender transition; and (b) The applicant has been stable in the preferred gender for 18 months; and (c) If the applicant is presently receiving cross-sex hormone therapy post­ gender transition, the individual has been stable on such hormones for 18 months. 7 Attachment 3 DTM-19-004, March 12, 2019 (3) A history of sex reassignment or genital reconstruction surgery is disqualifying, unless, as certified by a licensed medical provider: (a) A period of 18 months has elapsed since the date of the most recent of any such surgery; and (b) No functional limitations or complications persist and any additional surgery is not required. c. In-Service Transition. Service members who are exempt may continue to receive all medically necessary treatment, as defined in DoDI 1300.28, to protect the health of the individual, obtain a gender marker change in the Defense Enrollment Eligibility Reporting System (DEERS) in accordance with DoDI 1300.28; and serve in their preferred gender. d. Separation And Retention. Service members who are exempt: (1) May not be separated, discharged, or denied reenlistment or continuation of service solely on the basis of gender identity. (2) May be retained without a waiver pursuant to this DTM. A Service member whose ability to serve is adversely affected by a medical condition or medical treatment related to his or her gender identity or gender transition should be treated, for purposes of separation and retention, in a manner consistent with a Service member whose ability to serve is similarly affected for reasons unrelated to gender identity or gender transition. 2. SECTION II: NONEXEMPT INDIVIDUALS . a. Applicability. Individuals are not exempt if they do not meet the criteria in Paragraph l .a. of this attachment. b. Appointment, Enlistment, or Induction into the Military Services. Individuals who are not exempt will be accessed or commissioned based on the following medical standards, provided they are medically qualified in all other respects in accordance with DoDI 6130.03 : ( 1) A history or diagnosis of gender dysphoria is disqualifying unless: (a) As certified by a licensed mental health provider, the applicant demonstrates 36 consecutive months of stability in the applicant' s biological sex immediately preceding submission of the application without clinically significant distress or impairment in social, occupational, or other important areas of functioning; and (b) The applicant demonstrates that the applicant has not transitioned to his or her preferred gender and a licensed medical provider has determined that gender transition is not medically necessary to protect the health of the individual; and 8 Attachment 3 DTM-19-004, March 12, 2019 (c) The applicant is willing and able to adhere to all applicable standards, including the standards associated with the applicant's biological sex. (2) A history of cross-sex hormone therapy or a history of sex reassignment or genital reconstruction surgery is disqualifying. (3) The accession standards will be reviewed no later than 24 months from the effective date of this DIM, and every 24 months thereafter, and may be maintained or changed, as appropriate, to ensure: (a) Consistency with applicable medical standards and clinical practices; and (b) The readiness and combat effectiveness of the Military Services. c. In-Service Transition. Individuals who are not exempt must adhere, like all other Service members, to the standards associated with their biological sex. These nonexempt Service members may consult with a military medical provider, receive a diagnosis of gender dysphoria, and receive mental health counseling, but may not obtain a gender marker change in DEERS or serve in their preferred gender. d. Retention. Service members who are not exempt may be retained without a waiver if they receive a diagnosis of gender dysphoria on or after the effective date of this DIM, provided that: (1) A military medical provider has determined that gender transition is not medically necessary to protect the health of the individual; and (2) The Service member is willing and able to adhere to all applicable standards, including the standards associated with his or her biological sex. e. Separation. Service members who are not exempt: (1) May not be separated, discharged, or denied reenlistment or continuation of service solely based on gender identity. (2) May not be separated solely based on a diagnosis of gender dysphoria without first being medically evaluated for possible referral to the Disability Evaluation System (DES) pursuant to DoDI 1332.18 or the USCG Physical Disability Evaluation System (PDES), pursuant to Commandant Instruction (COMDTINST) Ml 850.2 (series). (3) If referral to the DES is not appropriate in accordance with DoDI 1332.18 or the USCG PDES, in accordance with COMDTINST M1850.2 (series), may be subject to processing for administration separation in accordance with Attachment 4 and the following guidance: 9 Attachment 3 DTM-19-004, March 12, 2019 (a) The Secretary of the Military Department concerned or the Commandant, USCG, may authorize separation based on conditions and circumstances not constituting a physical disability that interfere with assignment to or performance of duty. l. Service members are ineligible for referral to the DES or USCG PDES when they have a condition not constituting a physical disability as described in DoDI 1332.18 or COMDTINST M1850.2 (series). 2_. Service members may be referred to the DES or USCG PDES if they have a diagnosis of gender dysphoria and of co-morbidities that are appropriate for disability evaluation processing in accordance with DoDI 1332.18 or COMDTINST Ml 850.2 (series), before processing for administrative separation. (b) Service members with a diagnosis of gender dysphoria may be subject to the initiation of administrative separation processing in accordance with Paragraph 2.e. of this attachment if they are unable or unwilling to adhere to all applicable standards, including the standards associated with their biological sex. (c) Nothing in this guidance precludes appropriate disciplinary action for Service members who refuse orders from lawful authority to comply with applicable standards. 3. SECTION III. ADDITIONAL POLICY GUIDANCE. a. Waivers. (1) The Military Departments and the USCG may grant waivers, in whole or in part, to the requirements in this attachment in individual cases. (2) If a waiver is granted permitting an applicant or Service member, who is not exempt under Paragraph 1 of this attachment, to serve in his or her preferred gender, such an individual will be considered from that point forward to be exempt in accordance with Paragraph 1. (3) The provisions concerning who may qualify as exempt under Paragraph I .a. of this attachment may not be waived; a person who is exempt under Paragraph I .a. may not have his or her exempt status revoked. b. Medical Policy. (1) For Service members who have been diagnosed with gender dysphoria and are exempt, the Military Departments and Services will handle requests for medical care and treatment in accordance with DoDI 1300.28 and the July 29, 2016 Assistant Secretary of Defense for Health Affairs Memorandum. 10 Attachment 3 DTM-19-004, March 12, 2019 (2) For Service members who have been diagnosed with gender dysphoria and are not exempt, the Military Departments and the USCG: (a) Will provide necessary care consistent with Section 1074 of Title 10, United States Code and the July 29, 2016 Assistant Secretary of Defense for Health Affairs Memorandum for as long as the individual remains a Service member as set forth in a medical treatment plan developed with the military medical provider and provided to the commander. (b) Will take appropriate action to facilitate the continuity of health care consistent with DoDI 6490.10 if the Service member is to be separated from military service. c. Equal Opportunity. The DoD and the USCG provide equal opportunity to all Service members, in an environment free from harassment and discrimination on the basis of race, color, national origin, religion, sex, gender identity, or sexual orientation. d. Protection of Personally Identifiable Information (PII) and Protected Health Information. (1) The Military Departments and the USCG will: (a) In accordance with DoDI 5400.11, in cases where there is a need to collect, use, maintain, or disseminate PII in accordance with this issuance or Military Department and Service regulations, policies, or guidance, protect against unwarranted invasions of personal privacy and the unauthorized disclosure of such PII. (b) Maintain such PII so as to protect the individual's rights, consistent with federal law and policy. (2) Disclosure of protected health information will be consistent with DoD 6025.18-R. e. Education And Training. Revised training will occur at the Military Department' s and USCG's discretion. f. Other. The Military Departments and Military Services recognize a Service member's status as male or female by the member's gender marker in the DEERS. (1) The Military Services apply all standards that involve consideration of the Service member's status as male or female on the basis of the member's gender marker in DEERS such as: (a) Uniforms and grooming. (b) Body composition assessment. (c) Physical readiness testing. 11 Attachment 3 DTM-19-004, March 12, 2019 (d) Military Personnel Drug Abuse Testing Program participation. (2) As to facilities subject to regulation by the Military Departments and the USCG, the Service member will use those berthing, bathroom, and shower facilities associated with the member' s gender marker in DEERS. 12 Attachment 3 DTM-19-004, March 12, 2019 ATTACHMENT 4 PROCESSING CHANGES TO DoDis 1332.14 AND 1332.30 1. The following will be added to DoD Instruction 1332.14, Enclosure 3, Paragraph 3.a.(8): "(h) The Secretary concerned may authorize separation on the basis of conditions and circumstances not constituting a physical disability that interfere with assignment to or performance of duty based on a diagnosis of gender dysphoria where the Service member is unable or unwilling to adhere to all applicable standards, including the standards associated with his or her biological sex, or seeks transition to another gender. l. Separation processing will not be initiated until the enlisted Service member has been formally counseled on his or her failure to adhere to such standards and has been given an opportunity to correct those deficiencies, or has been formally counseled that his or her indication that he or she is unable or unwilling to adhere to such standards may lead to processing for administrative separation and has been given an opportunity to correct those deficiencies. i. Separation processing will not be initiated until the enlisted Service member has been counseled in writing that the condition does not qualify as a disability." 2. The following will be added to DoD Instruction 1332.30, Paragraph 9.2.d.: "d. The Secretary concerned may authorize separation of a commissioned officer on the basis of conditions and circumstances not constituting a physical disability that interfere with assignment to or performance of duty based on a diagnosis of gender dysphoria where the commissioned officer is unable or unwilling to adhere to all applicable standards, including the standards associated with his or her biological sex, or seeks transition to another gender. (1) Separation processing will not be initiated until the commissioned officer has been formally counseled on his or her failure to adhere to such standards and has been given an opportunity to correct those deficiencies, or has been formally counseled that his or her indication that he or she is unable or unwilling to adhere to such standards may lead to processing for administrative separation and has been given an opportunity to correct those deficiencies. (2) Separation processing will not be initiated until the commissioned officer has been counseled in writing that the condition does not qualify as a disability." 13 Attachment 4 DTM-19-004, March 12, 2019 GLOSSARY PART I. ABBREVIATIONS AND ACRONYMS DEERS DES DoDI DTM Defense Enrollment Eligibility Reporting System Disability Evaluation System DoD instruction directive-type memorandum PDES PII Physical Disability Evaluation System personally identifiable information USCG USD(P&R) United States Coast Guard Under Secretary of Defense for Personnel and Readiness PART II. DEFINITIONS These terms and their definitions are for the purpose of this issuance. biological sex. A person' s biological status as male or female based on chromosomes, gonads, hormones, and genitals. cross-sex hormone therapy. The use of feminizing hormones in an individual with a biological sex of male or the use of masculinizing hormones in an individual with a biological sex of female . gender identity. An individual ' s internal or personal sense of gender, which may or may not match the individual ' s biological sex. gender marker. Data element in DEERS that identifies a Service member' s status as male or female. gender transition. A form of treatment for the medical condition of gender dysphoria may involve: Social transition, also known as "real life experience," to allow the patient to live and work in his or her preferred gender without any cross-sex hormone treatment or surgery and may also include a legal change of gender, including changing gender on a passport, birth certificate, or through a court order; or Medical transition to align secondary sex characteristics with the patient's preferred gender using any combination of cross sex hormone therapy or surgical and cosmetic procedures; or 14 Glossary DTM-19-004, March 12, 2019 Surgical transition, also known as sex reassignment surgery, to make the physical body, both primary and secondary sex characteristics, resemble as closely as possible the patient's preferred gender. PII. Information used to distinguish or trace an individual's identity, such as name, social security number, date and place of birth, mother's maiden name, biometric records, home phone numbers, other demographic, personnel, medical, and financial information. PII includes any information that is linked or linkable to a specified individual, alone, or when combined with other personal or identifying information. preferred gender. The gender with which an individual identifies. stable or stability. The absence of clinically significant distress or impairment in social, occupational, or other important areas of functioning associated with a marked incongruence between an individual's experienced or expressed gender and the individual' s biological sex. transgender. Individuals who identify with a gender that differs from their biological sex. 15 Glossary