Mental health considerations with transgender and gender nonconforming clients

Mental health in the context of primary care

Mental health is vital to positive physical outcomes and, as for all patients, should be addressed for transgender patients in primary care. Due to pathologization and mistreatment by mental health professionals, transgender people are often reluctant to engage with mental health providers.[1,2] Primary care settings may offer a safer environment for transgender people to bring up mental health concerns and may be easier to access than mental health services. Every intake for care should include a mental health history and an assessment for active mental health concerns. Screening should include primary mental health problems, environmental and social stressors, and gender-related needs. Screening also requires provision of appropriate referrals to transgender-affirming mental health services when needs are identified.

Mental health concerns endorsed by a patient should not be automatically assumed to be related their gender identity.[1] Transgender people may be seeking mental health care for a number reasons; in addition to mental health issues relating to or resulting from one's gender identity, transgender people do experience the background rates of mood disorders and other psychiatric conditions seen in the general population. While some may be seeking specific assistance for gender-related themes, others are seeking assistance with depression, anxiety, or other clinical concerns unrelated to their gender identity.[3]

Primary care should be trauma-informed in its delivery, with an understanding that many patients present with complex trauma histories with interpersonal, social and medical systems-based trauma experiences.[4] Trauma-informed care and training for all staff and providers can enhance care engagement and health outcomes. In a recent publication, Machtinger and colleagues describe a theoretical framework for providing trauma-informed primary care.[5] The model is based on the needs of women who have a history of trauma. The model proposes the need to address the primary care environment, patient screening, provider response to the patient's needs, and a foundation of organizational values that support trauma informed care across all levels of the organization. Machtinger and colleagues address the need for confidential spaces in which to conduct a thorough screening of a patient's history with a special emphasis on trauma and a patient's response. Being able to speak with a provider in a place that ensures privacy is critical. 

Primary mental health needs of transgender people

Transgender and gender nonconforming people, in general, have three types of need for mental health.

1. Exploration of gender identity. This includes determining exactly what one's gender identity is, coming to terms with this gender identity, self-acceptance and individuation, and exploring individual–level ways to actualize this identity in the world. This may also include preparation and assessment for various gender affirming treatments and procedures.
2. Coming out and social transition. This includes coming out to family, friends, and coworkers, dating and relationships, and developing tools to cope with being transgender in a sometimes transphobic world.
3. General mental health issues, possibly unrelated to gender identity. The variety of mental health concerns experienced by transgender people include mood disorders, generalized anxiety, substance abuse, and post-traumatic stress disorder (PTSD).[6]

Transgender people may seek services from mental health providers when they come to realize that their gender identity does not match the sex they were assigned at birth, or when the distress of this incongruence becomes intolerable. The age at which this realization occurs, and the age at which treatment is initially sought, may vary greatly from one person to the next. It should not be assumed that arrival at this realization or seeking treatment late in life indicates that an individual is any "less" transgender.[1]

The coming out process for transgender people can be more challenging than it is for lesbian, gay, and bisexual (LGB) people, primarily because LGB may be able to keep their sexual orientation undisclosed. Due to the nature of social and medical transitions, a transgender person must come out to people with whom they interact unless they relocate and choose to live "in stealth" (i.e. not divulging their transgender identity). The coming out process can be time consuming and emotionally challenging. This process can be gender affirming when transgender people are supported in doing so. Conversely, a lack of support or experiences of being mistreated, harassed, marginalized, defined by surgical status, or repeatedly asked probing personal questions may lead to significant distress.

Approaches to supporting transgender people during the coming out and exploration process include reinforcing self-identification, and exploration of and integration of individualized identity. This in turn will provide a supportive foundation for interacting with unsupporting partners, friends, relatives or coworkers, as well as provide needed tools to diffuse and deflect potential implicit and unconscious transphobic messaging and rejection in everyday life.

Transgender people experience the background rates of common mood disorders, bipolar disorder, schizophrenia etc. that are seen in the general population, as well as a potentially increased rate of some conditions as a result of chronic minority stress and discrimination.[7] Hendricks and Testa have extended Meyer's Minority Stress Model [8] to transgender people.[9] This model addresses the ways that proximal and distal challenges increase the likelihood that a person will experience mental health challenges. Related to this is the work conducted by Nadal addressing microaggressions (e.g., everyday slights).[10] Similar to the concerns for mental health disorders addressed by Hendricks and Testa, Nadal's work also points to the increased risk of mental health concerns for transgender people.

Routine primary care visits should include screening for co-occurring mental health conditions, past treatments, and history of suicide and self-injurious behaviors, symptoms of posttraumatic stress, and substance use. Primary care providers should be equipped to handle basic mental health needs of transgender patients (e.g., depression and anxiety) just as any other patient. Any primary mental health concerns beyond the scope of the provider's routine practice should be referred to transgender-affirming mental health providers. Referrals should be made when appropriate to substance abuse treatment programs, including dual diagnosis programs for those with co-occurring mental illness. All primary care offices should have a clear suicide response plan for any patient endorsing thoughts of suicide. Trans Lifeline is a crisis hotline staffed by and for transgender people and can be included in safety planning with patients.[11]

Transgender people seeking care for mental health concerns require culturally competent providers.[1] This includes basic knowledge gender identity. Transgender patients should not be placed in the position of training their providers about their mental or physical health care needs.

Environmental and social considerations

Environmental and social stressors greatly impact mental health. Transgender people are more likely to live in poverty, be discriminated against in employment, and be victims of violence than non-transgender people.[12] Transgender people also face higher rates of family loss, and homelessness. Transgender people with intersecting identities such as race, ethnicity, or socioeconomic status face increased likelihood of adverse life events. Transgender women of color face extraordinarily high rates of social and health disparities.[13-16] Routine primary care visits should always assess for housing, food, financial, and safety concerns in living and/or work environments. Case management services should be provided within the primary care setting if available. Due to environmental stressors, transgender people may have secondary adjustment difficulties including depression, anxiety, and trauma reactions. Offering referrals for individual and group therapy and support can bolster protective factors in lieu of the extreme hardships many endure.[17,18]

Diagnosis of gender dysphoria

According the Diagnostic and Statistical Manual for Mental Disorders (5th ed.) a person may be diagnosed with a mental health disorder ("Gender Dysphoria") if their gender identity does not match the sex they were assigned at birth, and they are suffering clinically significant distress or social/occupational impairment.[6] A diagnosis may provide an explanation for their gender concerns. However, receiving a Gender Dysphoria diagnosis may be perceived as pathologizing.[19] The issue of diagnosis is further complicated by a lack of a diagnostic code for the care of those with a history of gender transition of some kind who no longer experience significant distress or social/occupational impairment. In some cases patients will have a carve-out of mental health services from their medical plan. It is possible that in these cases medical benefits may be denied under the medical plan for transition related care, since the only current ICD10 Gender Dysphoria codes are in the mental health section. A process is in place to create an expanded and more relevant set of codes for ICD11. Insurance plans in some states exclude coverage even if the care has been deemed to be medically necessary.[20] In states that ban health insurance exclusions, or if the individual's insurance includes transgender care, a diagnosis of Gender Dysphoria may be required for insurance to pay for necessary medical and surgical treatment.

Gender identity - specific considerations

Different gender identities and differences of gender expression are not pathologies.[21] However, some transgender people seek mental health services related to their gender. Often, distress is present over the extreme social and environmental difficulties transgender people encounter and they are seeking care to assist with these stressors. Transgender people may also seek mental health services with distress that gender does not match the sex they were assigned at birth or to discuss social and medical avenues available to live as a different gender.

Transgender patients frequently access primary care providers to discuss initiation of cross-sex hormones. Primary care providers who are experienced in working with transgender patients may feel comfortable initiating hormone therapies without an initial mental health assessment using an informed consent model(Grading: T O S).[22] The informed consent process includes addressing the medical and social risks and benefit of hormone treatment. Setting up a separate appointment for this process can be helpful to ensure the patient is given adequate time to review the information and address any questions the patient may have. Informed consent should be reviewed in person to best meet all patients' health literacy needs.

The World Professional Association for Transgender Health (WPATH) publishes the Standards of Care (SOC).[23] The SOC outlines a process for the initiation of cross-sex hormones. Per the SOC, an assessment by an experienced clinician - a primary care provider or mental health professional -- is required for initiation of cross-sex hormones. This assessment establishes the presence of persistent gender dysphoria and the ability to give informed consent. Exploration of risks and benefits of treatment to give informed consent should include not only the medical risks and benefits of treatments, but also possible social risks and benefits (such as the risks to employment, relationships, and housing), and ways to navigate and mitigate these risks. Therapy is not required to initiate a medical transition, but is encouraged to address any concerns that might arise during the process.[23] The SOC are intended to be flexible and taken on a case-by-case basis.[23] Removal of the gatekeeper role from mental health providers allows a more open and therapeutic relationship to be formed with mental health providers.

If mental illness impairs a patient's capacity for informed consent, referrals for further mental health assessment and treatment should be made prior to initiation of treatment. SOC recommends stabilizing co-occurring mental illness prior to initiation of hormones, but in some cases the medical treatment of gender dysphoria is best done simultaneously with treatment of mental illness and substance use disorders.[24]

Some patients presenting for initial primary care services may already be on hormones. When a physician has previously prescribed these hormones no new mental health assessment is required for continued hormone treatment. Hormones and standard maintenance of physical and laboratory assessments should be continued after a discussion with the patient about their continued goals of care.

Providers are encouraged to review the tasks of the mental health provider as outlined in the SOC.[23] This document outlines the various activities of mental health providers. This might include assessment, counseling, and medication management. The SOC requires one or two evaluations by mental health professionals prior to certain surgeries for transgender people, including chest and genital surgeries. The requirements for each surgery and evaluation letter are listed in the SOC, and mental health providers can access further training online in performing these assessments.[25] See Table 1 for an explanation of the required evaluations and related referral letters. Providers are encouraged to be cautious with psychological assessment tools that were not designed for use with transgender people.

The preoperative assessment process has historically been focused on making a diagnosis of gender dysphoria, determining capacity to provide informed consent, and assessing for certain specific criteria (i.e. length of time taking hormone therapy). However, recovery from gender affirming surgeries can be complex and involved processes, and there is an additional need for assessment of overall psychosocial functioning and support, health literacy, capacity for self-care, and social support structure in place. There is also a need to provide basic education about the surgical procedure, and provide support to fill in gaps identified during the assessment process. This need has increased with the advent of expanded access to surgery among a broad range of persons, including those who are medically indigent. A framework has been proposed in which this entire process, including the WPATH assessment, should occur (Fig 1).[26] This framework includes an evaluation of psychosocial functioning, housing status, social support system, transportation, health literacy and access to emergency care in the postop period.

Assessments ("letters") required for gender-affirming medical treatment

Procedures other than those listed below do not require a formal assessment process, though in some cases an assessment and preparation may be indicated, as with any surgery. In some cases, an assessment and letter from a medical provider who has initiated hormone therapy using an informed consent approach may be appropriate.

Figure 1. Framework for perioperative assessment, preparation, and care navigation

Credit: 

Adapted from: Deutsch MB. Gender-affirming Surgeries in the Era of Insurance Coverage: Developing a Framework for Psychosocial Support and Care Navigation in the Perioperative Period. J Health Care Poor Underserved; May 2016.

This figure illustrates the types of assessments to implement (functional, WPATH, education and resources) before and after gender-affirming surgeries, and the general sequence to be used. First is a functional assessment, which includes housing, health literacy, social and family support, and psychological functioning. Second is the WPATH assessment, which includes diagnosis, eligibility and readiness assessment, and informed consent. At this point, the patient may join a waiting list. An education and resources assessment includes physical, emotional, infrastructure, and knowledgebase and may be done while awaiting a surgery dates. Just prior to surgery, reassess functional readiness, adding topics like recovery location, transportation, and assistance. After surgery and immediate postoperative care, reassess housing and social and family support, psychological functioning, postoperative care navigation, and urgent/emergent care navigation. This concludes the surgical phase.

Counseling can be an important aspect of care for transgender people. For those patients seeking a mental health consultation or psychotherapy prior to the initiation of gender affirming hormone therapy, there is no minimum requirement for number of sessions or period of time in therapy.[23] As stated above, providers must use caution about the reason for clinical services and not assume that care is related only to immediate gender dysphoria. It is important to normalize for patients any experiences related to grief and loss. Any transition a person makes in their life may include experiences of loss, regardless of the reason for the loss.

Finally, some mental health providers are trained and licensed to manage psychotropic medications for transgender people. Similar to counseling, this can be an important part of care when a patient has a co-occurring mental health concern for which medication is indicated. In some states psychologists have prescriptions privileges. In most states though, these services will be offered by psychiatrists, primary care physicians, nurse practitioners, or physician assistants.

Harm reduction

Other transgender patients may have obtained hormones by other means, such as the internet or street sources, without initial or ongoing medical assessment or supervision. The SOC has provisions for physicians to continue the medical treatment of patients who have independently initiated cross-sex hormone therapy, regardless of the patient's ability or desire to receive gender-related psychiatric/psychological evaluation.[23] Physicians may provide treatment based upon the principle of harm reduction. When patients have demonstrated their determination to continue using medication(s) without physician oversight, then it is advisable to assume their medical care and prescribe appropriate hormones. Denial of care will likely result in continued independent treatment and possible harm.

Finding a mental health provider

Making a referral to a provider who is culturally competent can be challenging. This is due, in part, to the lack of training.[27,28] Although this has been changing in recent years, it can still be a challenge. Large cities with LGBT Health Centers and providers known to offer competent care to transgender people have become a reliable source of care. Often there is a network of mental health providers in these cities. For transgender people who live in rural settings or in conservative areas of the country, finding a provider for referral can be more challenging.[16] Some providers will offer tele-mental health services. However, it is important to assure that the provider is licensed in the jurisdiction where the client is receiving services.

Patients should be encouraged to reach out to possible providers and be prepared to ask questions to assure that the provider will be able to meet their needs. Some providers will offer an initial consultation at no cost. This allows an opportunity to determine if the provider will be a good fit. A list of providers by U.S. state can be found through the WPATH website. [29]

Collaborative care

Mental health providers are encouraged to create interdisciplinary relationships.[30] Transgender people, especially those who pursue gender affirming treatments and procedures, will require care from a variety of providers. This might include primary care physicians, endocrinologists, and surgeons. Providers are encouraged to seek out the names of providers in their area who are known to provide affirmative care with transgender clients and patients.

Summary

Transgender people deserve to receive mental health services from providers who are culturally competent. Trans-affirmative care assumes that the clients understand their own experience and identity. Providers should approach each individual with cultural humility, and avoid making assumptions or projections based on prior patients, experiences, or preconceptions. Providers are reminded to treat all clients with dignity and respect.

References

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