How psychiatrists can improve transgender care

A US Transgender Survey data found 39% of participants were currently experiencing serious psychological distress, nearly eight times the rate in the US population.

Mental health professionals are likely to work with patients who are transgender or gender diverse (TGGD) and should work to create an accepting, supportive and safe space for these patients, according to the University of Cincinnati's Melanie Thomas-Castillo, PsyD, and Stephen Rush, MD. They recently published commentary on the topic in Current Psychiatry.

The authors said the article was written to provide mental health professionals with an understanding of the perspective TGGD individuals bring to treatment. The higher rates of mental health disorders among TGGD people is likely due to social stigma and discrimination associated with their minority status, including within health care interactions, they said.

"This population has historically been pathologized within health care, leading to distrust and avoidance of providers," said Thomas-Castillo, assistant professor of Psychiatry and Behavioral Neuroscience in the UC College of Medicine and a UC Health clinical psychologist. "When individuals present for psychiatric care, they are often at their most vulnerable. It is imperative for mental health professionals to be able to provide an accepting and supportive environment in order to create safe space for TGGD patients to heal."

Mental health professionals should educate themselves and make active efforts to learn more about their TGGD clients, the authors argue. They recommend providers take steps including asking for each patient's preferred name and pronouns and using gender neutral language when getting to know a person to make interactions more welcoming.

"Introducing yourself with your own pronouns is a way to show that you are aware of the importance of pronouns and normalizes the process of introducing them at the start of an interaction," Thomas-Castillo said. "Being humble by acknowledging what you do not know can also show patients/clients that they are the experts on their own experiences, but you are interested in learning and understanding them."

Creating a safe environment does not mean providers will be perfect, but it can encourage patients to advocate for what they need by knowing they will be supported.

"I know of patients feeling comfortable enough to reach out to a provider to let them know that the wrong pronouns were used in their chart. The provider was able to take responsibility for the error in a non-defensive way and correct the chart immediately," Thomas-Castillo said. "This creates a dynamic in which the patient feels their identity and experiences are important within the treatment and allows them to continue to let the provider know if something within the treatment does not fit for them."

While progress has been made in de-pathologizing TGGD patients, the authors note that mental health professionals are often still placed in a "gatekeeping" role by being asked to provide letters of support before a patient can receive gender-affirming care. Research suggests access to gender-affirming care—including hormone replacement therapy, gender-affirming surgery, voice therapy and other treatments—can improve mental health issues in TGGD patients.

"It is in this way we in psychiatry must do more than just care for our patients by becoming advocates for them to receive the care they need and deserve," Thomas-Castillo and Rush wrote.

Even if individual providers do not think these barriers should be in place, they should strive to assess and support patients the best they can so that they can receive this care.

"When I am completing an assessment for gender affirming care/surgery, I talk to the individual about the nature of my role. I inform them that I am not here to decide whether they should be allowed to receive surgery or other care, but rather to talk through the process of surgery and explore their plan for pre- and post-operative care and support," Thomas-Castillo said. "I make clear that they are the expert on their experiences and needs and I am there to support them in the process of their gender affirming care."

Thomas-Castillo said it is important for psychiatric providers to "connect with and understand the fears, concerns and needs" of TGGD patients, particularly in light of current efforts to actively reduce the availability of care for these individuals.

"Advocating for the needs of our patients, whether TGGD or other communities, is necessary to ensure they continue to have appropriate access to care," she said.