Best practices suggested for psychiatric care of transgender and gender-diverse people

In caring for transgender and gender diverse (TGD) people, psychiatrists should focus on alleviating the sequelae of gender minority stress, with the goal of promoting resilience, according to a review published in Harvard Review of Psychiatry.

"We envision a role for psychiatry that goes beyond gatekeeping gender-affirming hormone therapy and surgeries," says Alex Keuroghlian, MD, MPH, Michele and Howard J. Kessler Chair and Director of the Division of Public and Community Psychiatry at Massachusetts General Hospital in Boston, and colleagues. "Instead, we should invest in equitable care across the continuum of mental health needs."

Psychiatric assessment prior to gender-affirming care

The World Professional Association for Transgender Health 2022 guidelines recommend discontinuing the practice of requiring mental health assessment before gender-affirming medical or surgical care, the authors note.

Patient regret and desire to detransition are infrequent consequences, and there is little evidence that psychiatric pre-assessment has any bearing on their likelihood. A better option is for clinicians providing gender-affirming care to document informed consent after discussing the benefits and potential risks of intervention.

Dr. Keuroghlian and co-authors offer practical guidance for offering responsive and high-quality psychiatric care to TGD individuals. Some key topics they discuss are:

Managing psychiatric illness

In general, diagnosis and treatment of psychiatric illness among TGD people are not intrinsically different than in cisgender people. However, suicidal ideation, for example, is associated with internalized transphobia, expectations of rejection, and identity concealment. When developing a comprehensive plan for depression in a TGD patient, it is important to account for gender minority stress.

As another example, many TGD people experience chronic societal rejection that can lead to increased vigilance. This response to gender minority stress needs to be distinguished from the rejection sensitivity that is characteristic of borderline personality disorder.

Interplay of psychopharmacology and gender-affirming hormone therapy

Psychiatrists should familiarize themselves with the nuances of prescribing psychotropic agents to TGD patients. For example, lamotrigine and estrogen may have bidirectional effects on serum levels, so it's prudent to check both medication levels when changing doses of either. Risperidone is known to cause hyperprolactinemia, which can result in unwanted gynecomastia and subsequent gender dysphoria among transmasculine people. In these patients, it may be important to monitor prolactin levels closely.

Additionally, clinicians should discuss prolonged erections related to trazodone and the reduced erectile function commonly experienced with selective serotonin reuptake inhibitors. TGD patients may variously perceive these phenomena as advantages or exacerbations of gender dysphoria.

Acute psychiatric settings

Case studies have noted gender dysphoria in patients experiencing psychosis; gender-affirming care is often withheld in these situations. A comprehensive clinical history, however, may reveal gender diversity that predates the psychosis. Endorsement of gender diversity during a psychotic episode may relate to disinhibition rather than delusional thinking.

Likewise, fluctuating gender identity in a patient with suspected psychosis should not be considered supportive of that diagnosis. Psychiatrists should nonjudgmentally work with the patient as they come to understand their gender identity (e.g., nonbinary, gender-fluid) and help disentangle delusional thinking from simple uncertainty about gender identity. Notably, continuation of gender-affirming hormone therapy is recommended during acute mental health crises.

TGD people often fear being pathologized and may be uncomfortable with group therapy and psychiatric medication, Dr. Keuroghlian and colleagues note. They are also likely to lack access to gender-affirming mental health care, especially TGD people of color. The authors emphasize "the importance of further educating clinicians and staff at mental health care facilities, and approaching care in an individualized, culturally responsive, and patient-centered manner."