Intersex Patients in Military Service

INTRODUCTION

Sex determination and differentiation is a complex process, influenced by the presence of a specific sex chromosome in the gonads and the sex-specific hormonal secretions from them, which in turn regulates the development of the embryo as a male or a female.1

Intersex is a rare congenital condition in which the development of sex chromosomes, gonads, and the anatomy of sex organs is atypical. In males, failure of androgen production or an inadequate response to androgen can cause incomplete masculinization in varying degrees. The most severe type is a complete sex reversal with a female phenotype.2

Androgen insensitivity syndrome (also known as androgen resistance syndrome) is a set of disorders of sexual differentiation that results from mutations in the gene encoding the androgen receptor, which is located on the Xq11-12 chromosome.3 Clinical presentation of this androgen resistance varies, depending on the expression level of the wild-type androgen receptor.4

The complete variation of androgen insensitivity syndrome (CAIS), previously termed testicular feminization, is inherited in a X-linked recessive pattern, in which only the nonandrogenic parts of male development exist (abdominal or inguinal testes), whereas external genitalia are feminine. Uterus and female adnexa are absent. Traditional treatment includes gonadectomy followed by estrogen replacement therapy to maintain feminine features. This operation is usually scheduled before early adolescence due to an increased risk for malignancy and before adult sexual identity establishment. However, early genital surgery is debatable, since the patients are too young to provide informed consent. In addition, the possible influences of circulating androgens, even in very low levels, on behavior and gender identity later in life are not fully elucidated.5

By late adolescence, most CAIS patients complete counseling, diagnosis, surgical treatment, and commence hormone replacement therapy (HRT). These patients are seen occasionally by pediatricians and endocrinologists in communitybased services. However, it is rare to encounter these patients in a military setting.

In this report, an intersex female soldier in a combat unit is presented. Her true medical condition (CAIS) was not reported in advance to the military health authorities and was disclosed only several months after her draft to the Israeli Defense Forces (IDF), posing both medical and ethical dilemmas to the primary military physician, as well as social and commanding challenges. To our knowledge, such a case was never described in that context.

CASE REPORT

A 19-year-old female soldier was assigned to a combat unit. Her training demanded intense and frequent physical activity, including lifting heavy weights, long distance foot marches, and cross-country runs.

After a few successful months in service as a trainee, she consulted a military primary physician, complaining about a constant fatigue and inability to continue with her current military service. Her medical history was unremarkable, whereas physical examination showed only nonspecific musculoskeletal tenderness. Just before concluding her visit, the soldier asked also to renew a prescription of oral contraceptives. The alert physician noted that the pills were unusual for women at her age, since they contained high-dose-conjugated estrogens only. After specific questioning, the physician discovered that the soldier was in fact diagnosed with CAIS (46, XY karyotype).

Familial History

History taking was focused on the patient's family and past medical history. Her parents were from a diverse origin and were not related. There were five siblings in the family: two (healthy) boys and three girls (the patient was the middle one). Figure 1 demonstrates her pedigree (the affected patient is labeled as D). The two older brothers (A and B) successfully completed their duty service in noncombat units.

Shortly after the diagnosis of the soldier's older sister (C, Fig. 1) with CAIS due to primary amenorrhea investigation, other family members were electively screened. Consequently, the described soldier and the youngest sister (D and E, respectively, Fig. 1) were also diagnosed with CAIS. By the age of 15, the described soldier underwent gonadectomy in a remote hospital and HRT was subsequently commenced. Endocrine follow-up was consecutive, and she was hormonally balanced. She described herself as being a "tomboy" in early childhood and adolescence, but had no explanations for that behavior. Nevertheless, all that information remained hidden from other relatives and from her primary care physician as well, since her parents felt shame to disclose the familial diagnosis. The patient was then followed up by an endocrinologist, a specialist in gender disorders, also intentionally away from her hometown.

The older sister is 11 months older than the described soldier (C, Fig. 1). She had also been drafted to service earlier, but was assigned to a noncombat unit. She also never reported her medical condition to the military health authorities and accomplished successfully her duty.

The younger sister is 5 years younger than the described soldier (E, Fig. 1). At that time, she had not been operated on yet and therefore did not start any HRT. In the near future, she is expected to be drafted, but she is still undecided regarding her ambitions for combat military service. Unless she declares her medical condition, the military medical triage system will not be able to recognize that she also has CAIS.

Medical Predraft Triage

Like in other countries, the medical predraft triage for IDF recruits is based on self-reported health questionnaires and on questionnaires signed by primary physicians who are familiar with the candidate's medical history in detail. However, in the presented case, the primary physician was not aware of the CAIS diagnosis. Since the discussed soldier never reported her true medical condition to military health authorities, it remained undisclosed. In this case, by choosing to hide her condition from health authorities, she gave wrong information.

Military Service

Motivated to serve, she was assigned to a combat unit. She successfully managed to perform her duties for several months while taking HRT she received elsewhere. An endocrine profile, performed shortly after CAIS disclosure, revealed very low testosterone level of 17 ng/dL (normal range for males, 300-1000 ng/dL; females, 20-80 ng/dL). This testosterone level was similar to earlier predraft measurements. It was assumed that the fatigue was associated with inadequate HRT dosage due to the increased stress level in her intense service. Therefore, HRT was adjusted with a gradual improvement. However, it did not enable her to continue with her combat service anymore. Endocrinology consultation affirmed that intersex soldiers should be kept from combat positions because of excessive physical stress.

To preserve confidentiality of medical information and specifically according to her personal request, her medical condition was never revealed to her commanders. In order not to disclose her true medical status, but yet allow her to accomplish her service with no further interruption, she was reassigned to a rear base as a trainer in her military profession. She fulfilled her 2 years of service with great satisfaction, without any physical or mental disabilities whatsoever.

DISCUSSION

The presented soldier introduced some challenging dilemmas to the primary military physician.

Prevalence of CAIS during Service

Intersex prevalence is estimated to be in the range of 0.018% to 1.7% in the general population.6,7 There is no conclusive data regarding intersex prevalence in Israel nor reports concerning military service of intersex patients. When considering parameters, such as the estimated prevalence and the drafted soldiers' number, one can expect that there are a few dozen intersex patients in active service in the IDF. By reviewing the data for all of the soldiers in service in the years 2004 to 2007, no similar intersex records could be retrieved. Therefore, we assume that this condition is underreported to military health authorities, most likely because of shame and secrecy, similarly to the presented reported patient. Another possibility is that some intersex patients are not eligible for draft due to mental health problems, such as gender identity disorder (International Classification of Diseases, 9th Revision, Clinical Modification 302.5). Although we reviewed the predraft triage medical data of the rejected recruits, we cannot comment on that possibility, since the documented diagnosis of gender identity disorder usually does not differentiate between organic and mental origins.8

Intersex Patients in Military Service

In the U.S. Army and U.S. Marines, the official policy is that individuals who identify as intersex, transgender, transsexual, or other sex-related disorders are medically problematic and/or psychologically disturbed; hence, they are not eligible to serve.9 In the Navy and U.S. Air Force, recruiters believed that intersex patients should be disqualified due to "the expected increased demand for medical treatments."9 On the contrary, military service of intersex individuals is accepted in countries such as Spain, Canada, Thailand, and the Czech Republic.10

In Israel, military service is mandatory for both males and females, and there is no official military policy which prevents intersex individuals from being drafted. Furthermore, in the Israeli society perspectives, successful military service is "normative." Therefore, in Israel, the policy which permits individuals with sex-related disorders to serve may contribute to their social recognition.

Combat Unit Assignment

Clearly, had the patient disclosed her true medical condition before being drafted, she would have never been assigned to a combat unit. Her continuous fatigue during the training period and her inability to continue the demanding military service were most probably attributable to the service physical and mental stress and could have been aggravated during combat service. This clinical presentation supports the current assignment policy.

Medical Triage

The patient's decision to hide medical information from military health authorities was done deliberately, as part of a general denial of her condition at that time, despite an earlier operation and current use of high-dose hormones. A predraft medical report was missing, since her primary physician was not familiar with her diagnosis. Currently, the military medical triage system in the IDF has only limited ways to receive complete medical data, especially from highly motivated candidates.

Clinical Approach

The decision not to enable the soldier to keep her combat position, even after balancing her hormonal profile, was taken to protect her from other stress-related harm due to the continued intense physical activity. This protective approach was adopted because of the rarity and the lack of experience in previous similar cases. Referral to a psychological interview was considered and offered, but was not carried out since the soldier refused any mental help.

Ethical Dilemmas

The presented soldier demonstrates possible contradictions for the primary military physician, between the oath to protect his patient's confidentiality and well-being (since the soldier refused to reveal her medical status) and the expected loyalty to the military system (which needs to assign only qualified soldiers to combat units). In that case, the military primary physician, who had to balance these diverse issues, convinced the highly motivated soldier to change her position without having to report the medical reason to the soldier's commanders. That can clearly have been done only when both commanders and soldiers fully trust their military physician.

The question of whether to report the younger sister's medical condition to the military health authorities against her will presents another ethical dilemma between the need for military health authorities to select combat soldiers properly and protect the health of soldiers from potential harm versus the need to protect her privacy and emotional wellbeing. Confidentiality is one of the cornerstones of the physician-patient relationship, patients expect that their health care will be kept confidential, and the physician's legal and ethical responsibilities mandate this. Nevertheless, under some circumstances, confidentiality should be sacrificed. This issue has been widely discussed in die literature.11,12 Because she had not been drafted yet, there is still time for debating.

Command Dilemma

Sharing the full medical information with the soldier's commanders could have helped to explain her transfer from the training base to another noncombat position, since they were surprised by her sudden leaving. However, reporting this would have harshly devastated her confidentiality since she specifically asked not to do so. Nevertheless, commanders chose to trust and support the decision of the military primary physician.

CONCLUSIONS

Although it is uncommon for the military physician to encounter an intersex soldier, occasionally a case is encountered so that physicians need to remain aware of this condition. We emphasize that military service of intersex individuals may pose medical and ethical dilemmas as well as social and command challenges. Therefore, the approach to such cases varies worldwide. We recommend respecting the will of intersex individuals to serve in the military and claim that, especially in Israel, this may be even regarded as a form of mental and social "reinforcement" approach. Moreover, individually "tailored" fair solutions for intersex soldiers within the military system, balancing soldier's physical abilities, the system's flexibility, and confidentiality limits, can be achieved if cautiously and creatively managed. Because we recommend avoiding excessive stress, intersex soldiers should not be drafted to combat units, yet can serve in other, less demanding military positions.

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