5 Minute Pearls: Psychiatric Care Considerations for Sexually and Gender Diverse Populations

Historically, the approach to caring for transgender and gender diverse people has unfortunately involved conversion efforts, efforts to change a person’s gender identity from transgender or gender diverse to cisgender. Studies, including ours, have shown that this approach of trying to convert a person’s gender identity is, in fact, very harmful and associated with a much higher risk of attempting suicide in one’s lifetime. Instead of trying to convert someone’s gender identity away from being transgender or gender diverse, the evidence-based and ethical approach to care for transgender and gender diverse people is a gender affirming approach. 

More and more research studies are showing the mental health benefits of a gender affirming approach. For example, our group has done studies showing that gender affirming hormone therapy from early adolescents onward is associated with better mental health outcomes in adulthood, including decreased odds of suicidal ideation compared to desiring and not accessing gender affirming hormone therapy. 

We also published a study showing that access to gender affirming surgeries compared to desiring and not accessing gender affirming surgeries is associated with better mental health outcomes, including decreased odds of suicidal ideation and suicide attempts. 

Another study we did found that access to pubertal suppression, use of gonadotropin releasing hormone analogs in early puberty, to press pause on development of secondary sex characteristics for transgender and gender diverse youth is associated with decreased odds of lifetime suicidal ideation. 

PSYCHIATRY’S HISTORY WITH GENDER AFFIRMING CARE

A gender affirming approach to mental healthcare involves believing and honoring whom our patients tell us that they are and providing services that affirm them in their gender identity and expression. 

Historically, psychiatry has imposed onerous mental health assessments on transgender and gender diverse people as a form of gatekeeping before they were able to access gender affirming medical and surgical interventions. These gatekeeping strategies often questioned and doubted whether the person was, in fact, transgender or gender diverse. 

A gender affirming approach involves instead focusing on informed consent. A transgender or gender diverse person will seek information about a particular gender affirming intervention. We’ll provide information about the intervention, the transgender or gender diverse person that makes a decision about whether they want to move forward with this care, and we then provide the care if they desire it. 

In order to provide optimal mental healthcare for transgender and gender diverse people, it’s important to understand the phenomenon of gender, minority stress and resilience.  Transgender and gender diverse people chronically, developmentally from early childhood throughout adolescence and across adulthood, experience everyday discrimination, victimization, microaggressions, frank violence, unfortunately at a much higher prevalence than the general population. 

And there’s very much an intersectional component to this where, for example, African-American transgender women are among the populations with the very highest incidents of hate crimes in the United States. This is, unfortunately, the horrific reality that many people are living with. 

Within a gender minority stress framework, stigma and discrimination over time can lead to certain challenges in general psychological processes like: 

• Coping skills
• Building safe interpersonal relationships
• Believing that things will never get better
• That nobody can be trusted
• That no one will ever love us

All of this external stigma-related stress can contribute to internal stigma related stress:

• Internalized transphobia
• Believing all of the negative things that society has to say about one’s gender identity or expression
• Expecting rejection because you’re so accustomed to it
• Identity concealment to prevent mistreatment or abuse

This external and internal stigma-related stress over time contributes to what we see in the research, which is a much higher prevalence of physical health problems in addition to a higher prevalence of:

• Depressive disorders
• Anxiety disorders
• Post-traumatic stress disorder
• Decreased self-care
• Decreased engagement in medical and mental health care

RESILIENCE AND ADAPTIVE COPING

While minority stress can present as a crisis, it’s also an opportunity to promote resilience and cultivate adaptive coping skills. Although transgender and gender diverse people shouldn’t have to be more resilient, the reality is that they very often do become more resilient in the face of societal adversity. It’s critically important to have a community led approach to this research, where community members should be involved in funding decisions related to transgender health research. Community members should be involved in the design, development and implementation of research studies focused on health for transgender and gender diverse communities, very much within the framework of “nothing about us, without us.” 

CALL TO ACTION: Develop Skills to Serve Transgender and Gender Diverse People

Ultimately, while it’s critically important for all healthcare professionals to develop cultural responsiveness and skill serving transgender and gender diverse people, many of the solutions we need to address mental health challenges are structural to replace existing discriminatory and biased policies against transgender and gender diverse people with policies that protect the safety and dignity of transgender and gender diverse people so that all can thrive and enjoy the same mental health outcomes as the general population.

 

Alex Keuroghlian, MD, MPH is an associate professor of psychiatry at Harvard Medical School and the Michelle and Howard J Kessler chair and director of the Division of Public and Community Psychiatry at Massachusetts General Hospital. Dr. Keuroghlian is a member of the editorial board for The Journal of Clinical Psychiatry. 

This is Five Minute Pearls for The Journal of Clinical Psychiatry, in partnership with the American Society of Clinical Psychopharmacology.