Resident Spotlight: Gender-Affirming Care is Mental Health Care

Eric Tran, M.D., MAHEC PGY-2 Resident

In 2016, the Williams Institute estimated that in the United States, 1.4 million adults identify as transgender, which represents 0.6% of the overall population.^[1] In 2017, the Institute reported that 150,000 youth aged 13-17 also identified as transgender, about 0.7% of the population.^[2] These numbers are more than double what they reported in 2003, probably because more people are comfortable identifying as transgender. Because such an identity is still quite stigmatized, these are still likely underestimates--even the 2016 report’s upper bound is close to 3 million.

I bring up these numbers to say a simple sentence: transgender and gender non-conforming people live everywhere. As an extension, transgender and gender non-conforming people needing somatic and mental health care are everywhere. For example, in the 2016 report, North Carolina is #16 for proportion of transgender people, outranking states like New York or Massachusetts. Another 2016 Williams Institute Report showed that 36% of the country’s transgender population and 35% of the country’s LGBT population reside in the South.^[3] In just two years at my residency in rural Western North Carolina, I’ve provided mental health care for dozens of transgender people in a variety of settings.

In addition, multiple studies have shown that transgender people suffer from disproportionate rates of mental health issues. The Campaign for Southern Equality recently released results from the largest survey of LGBT Southerners. Of the transgender responders, 80% reported having experienced depression, compared to the national average of just under 10%.^[4] Anxiety and suicidal thoughts and self-harm were also similarly higher in transgender respondents.

Because of the extent of these disparities and how likely we are to care for transgender and gender nonconforming people, we have both a duty and an opportunity to provide competent and meaningful care to this population.

Several professional organizations have guidelines and best practices. For example, the American Psychiatric Association’s “A Guide for Working With Transgender and Gender Nonconforming Patients” includes best practices, basic terminology, and templates for writing letters to insurers and surgeons for gender-affirming procedures.^[5] Cleveland Clinic Consult QD wrote “Working with Transgender Adolescents: A Primer for Psychiatrists,” which includes screening for gender dysphoria and exploring age-appropriate treatment referrals.^[6] The Fenway Institute’s National LGBT Health Education Center has a plethora of self-led modules about a variety of topics in transgender health.

Being transgender does not inherently cause mental health issues, but it is rather a result of cultural stigma. This extends to the healthcare world. In the Campaign for Southern Equality report, only half of transgender respondents felt comfortable seeking care, and more than half reported delaying care “sometimes, often, or always” due to concerns regarding their identity. So, in addition to these guidelines, I think there are philosophical ideas or ethos we can adopt to better welcome and care for transgender populations.

First, we can approach our clinical interactions as opportunities for therapeutic interactions. This can begin before we even meet our patients. Are there signs of an affirming practice in the waiting room (safe space stickers, brochures for LGBT resources, directions to a gender-neutral bathroom)? Do the intake forms allow patients to mark their identified gender and name; if so, do you have a chance to review them before calling their name out loud? Calling someone by their birth name (sometimes called “deadnaming”) or incorrect pronouns can be a form of psychological violence that can color the entire interaction. Even if there are fields on my intake form, I make it a habit to ask patients what they would like. As an example, I say: “Hello my name is Dr. Eric Tran. I use he/him/his pronouns. What would you like me to call you?”

Related, we can regard gender-affirming care as mental health care. Using someone’s correct gender and name doesn’t just avoid violence. It allows us to affirm that their identity is legitimate and being taken seriously. We often think of gender transition in terms of hormone replacement therapy and surgical intervention. But often before that, people may transition socially, which can involve using pronouns of identified gender, using a different name, and/or wearing clothing associated with identified gender.

Recognizing and respecting these earlier efforts can be a form of validation for all patients. And should someone like to transition with hormones or surgery, we can point them in the right direction if they don’t already have a provider. I know multiple other residents and attendings in the family medicine program who are either practiced in or want to learn about medical transition. Local LGBT resources--such Tranzsmission in my area of the state--will sometimes list trans-competent providers, as well. Given that gender affirming treatments have been correlated with positive mental health outcomes, I see this as not only as being in our wheelhouse, but also one of our duties. (citation needed)^[7]

Synthesizing these two points, I urge us to think of our practice of medicine as allyship to transgender communities. This can involve recognizing where we can and do not need to take a role in our patients’ care. In terms of taking action, we can know and cite the literature that gender affirmation leads to better mental health outcomes for transgender people. This may be to other providers, to parents, or insurers. I care for several adolescents who self-harm, and I’ve discussed with their parents and providers that helping them achieve a body they like may also help them want to preserve it.

In terms of not taking action, I think we should consider when we are acting as gatekeepers. Guidelines for gender affirmation will often mention referral to psychiatry; this more as an attempt to link people to care due to high rates of untreated mental health issues and not necessarily to screen for conditions that preclude transition. (As discussed above, transition can help mental health outcomes.) In some circumstances, such as surgery, we may be required to assess competency, but overall our role as gatekeeping should be minimal.

We are very likely to care for transgender people in our careers. We will likely see people on a continuum in their journey. But regardless, holding the spirit of gender-affirming, person-centered practice will guide us towards competent, effective care.

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