Dear Secretary Wilkie:
Our country has made a sacred commitment to care for those who have borne the battle, and that includes the more than 163,000 transgender veterans who have served their country in uniform. We urge the U.S. Department of Veterans Affairs (VA) to provide our nation's transgender veterans, all medically necessary treatments prescribed by a veterans' physician, including medically necessary procedures to treat gender dysphoria.
The VA itself explained in a 2016 Impact Analysis that the exclusion for "gender alterations" was originally based on an assumption that surgical treatments were not medically necessary, but it agreed that "surgical procedures are now widely accepted in the medical community as medically necessary treatment for gender dysphoria." Indeed, there is an overwhelming international consensus that medical treatments, including surgical treatments, are safe, effective, and medically necessary when clinically indicated to alleviate gender dysphoria. Leading medical associations agree that such treatment should be a covered benefit in programs such as the VA. America's leading medical and mental health organizations, including the American Medical Association, the American Academy of Nursing, the American College of Physicians, the American Medical Student Association, and the American Nurses Association, have argued against the VA's current ban on covering surgical treatment for gender dysphoria. They maintain that proper treatment of gender dysphoria, as determined between a patient and physician on a case-by-case basis, can include surgical treatment. These experts warned that by prohibiting VA physicians from recommending and providing this medically necessary care, the VA was contradicting established standards of care and placing transgender veterans at "substantially greater risk of serious physical and emotional trauma."
The VA, in its request for comment, is attempting to justify a continued ban on surgical treatment for gender dysphoria because it could lead to suicide and suicidal ideation among veterans. In particular, the VA cites the February 2018 Department of Defense report on "Military Service by Transgender Individuals" to suggest that there is "considerable scientific uncertainty" on the efficacy of medical treatments for gender dysphoria. This report was widely refuted by medical experts, who criticized its mischaracterization of the scientific consensus on the effectiveness of medical treatments for gender dysphoria.
In fact, evidence shows that denying patients access to this medically-recommended procedure can increase risk of suicide. As the medical community notes in their brief: "When not properly treated, gender dysphoria can result in clinically significant psychological distress, dysfunction, debilitating depression, and, for some people, self-mutilation, thoughts of and attempts at suicide, and death." 
This broad medical consensus on the treatment of gender dysphoria is based on decades of peer-reviewed studies and clinical observation--including studies of veterans--that demonstrate its efficacy and substantial health benefits. Studies have found that access to medical treatment, including surgical treatments when clinically indicated, substantially contribute to decreasing rates of suicidal ideation and behavior, including among transgender veterans. Additionally, numerous studies have found that access to these treatments is associated with substantial improvements in other measures of mental health closely tied to suicidality, including anxiety and depression.
Our nation's veterans have put their lives on the line to defend our freedoms, including the right to equality and to protection from discrimination. That our nation would ask our veterans to protect rights that we would not afford them in return is unacceptable. It is wrong to single out any group of veterans to deny access to medically necessary care. While transgender veterans represent a small percentage of the overall veteran population, transgender Americans are twice as likely to be veterans than the general US population. By excluding medically necessary treatments from its medical benefits package, the VA hurts transgender veterans who have served their country, harming their health and in some cases putting their lives at risk.
Simply put, the VA has an obligation to provide the necessary care that is prescribed to enrolled veterans by their health care practitioners. It is unconscionable to deny veterans the same access to health care services that civilians receive in the private sector, and that is available to Medicare beneficiaries and federal workers, simply because of outdated and unscientific prejudice against their gender identity.
As Members of Congress, we have repeatedly declared our commitment to caring for our veterans who have risked their lives to protect our essential freedoms. In providing this coverage through the Veterans Health Administration we affirm this commitment, ensuring our veterans will not have to face insurmountable debts and continued distress to realize their gender identity. Thank you for your attention to this important matter.