Christopher Daley, MD

The transgender community is a diverse group of individuals who self-identify in many ways (eg, transsexual, transgender, gender nonconforming). Members of the community commonly transcend society’s gender binary and widely assumed definitions of gender roles and instead identify within a spectrum of gender expression.

 (The gender binary is the traditional framework for understanding gender, including the culturally maintained belief that there are only 2 genders [men and women] and that gender must conform to biological sex [male and female].) A deficit of knowledge about optimal treatment for this population exists within the mental and medical health provider community, which contributes to the marginalization of transgender persons, for whom frequent barriers to health care access pose significant risks.

Using a question-and-answer format, we present a brief overview of issues that arise when mental health professionals explore how to best serve this population.

What terms referring to gender identity are most appropriate? How do I know which pronoun to use?

Many terms are used to refer to gender-nonconforming persons. The most common are transsexual, transgender, and gender nonconforming (

). It is important to understand that these terms are highly individualized and many have negative and/or suboptimal connotations.

The terms “MTF” (male-to-female) and “FTM” (female-to-male) are widely used in clinical notes and academic literature. However, the preferred terms are “transwoman” and “transman,” which are appreciated as the most affirming of the patient’s identity; they de-emphasize the pathology model, and reflect an active appreciation of the diversity model.

 The latter are more affirming terms and discourage users from thinking of transgender persons as “pre” and “post” surgery and/or “pre” hormone therapy, because these variables may or may not have any bearing on the person’s gender identity or the pronoun that is appropriate for the person.

If you are not sure which pronoun to use, you can ask the patient directly: “Which pronoun is appropriate?” rather than, “Which pronoun do you prefer?” For many people, the pronoun use is a clear identity rather than a preference.

 Your patient may respond with “he”; “she”; or a variety of other pronouns, such as “they” or “ze”-a commonly used gender-neutral pronoun in the English language. You can also ask, “How would you like to be addressed?” and “How would you like me to refer to you?”

Gender identity is about what’s between the ears rather than what’s between the legs. – Willy Wilkinson, MPH

What is the difference between gender nonconform-ing and gender dysphoria?

Gender dysphoria refers to a significant level of distress one may experience as a result of a gender identity that is incompatible with one’s sex at birth and/or primary and secondary sex characteristics.

 The distress is in response to having a different experience of one’s gender from societal expectations and the resulting discrimination, harassment, and lack of acceptance. The distress also arises from the commonly held belief that transgender persons are responsible for the discrimination they experience, rather than the idea that society should hold those who are biased against transgender persons accountable for their actions.

The term “gender nonconforming” refers to persons whose gender identity, role, or expression is distinct from cultural expectations of a particular sex.

 The concept of gender nonconforming is socially and culturally variable-what may be considered appropriate gender expression in one culture may be considered gender nonconforming in another, and vice versa. Not all gender-nonconforming individuals experience gender dysphoria.

What is already known about psychiatric care of transgender persons? 
? Transgender patients are a diverse community. They are often underserved because of limited cultural competence on the part of their providers.

What new information does this article provide? 
? This article describes the concept of a gender identity spectrum and defines key terms. It provides answers to clinicians’ frequently asked questions about working with transgender patients.

What are the implications for psychiatric practice? 
? Transgender health care is a rapidly growing field. All clinicians should be comfortable working with transgender patients and familiar with current guidelines for providing care for this population.

What percentage of the general population is transgender or gender nonconforming?

A multitude of factors contribute to the difficulty of performing epidemiological studies for this population and, hence, no formal studies have been conducted to determine the number of people who identify as transgender or in whom gender identity disorder (GID) has been diagnosed. Researchers have focused their efforts on the most easily quantifiable within the spectrum of gender-nonconforming persons: transsexual persons who have received hormones and/or have had surgeries.

A review of 10 studies based in Europe suggests that the prevalence of transwomen (MTF) ranges from 1 in 11,900 to 1 in 45,000 and that of transmen (FTM) ranges from 1 in 30,400 to 1 in 200,000.

 Statistics from the World Professional Association for Transgender Health (WPATH) and DSM-IV are based on decades-old data and are widely considered inaccurately low. Some researchers have theorized that the true prevalence is much higher because of inherent difficulties in estimation.

What is the prevalence of Axis I and Axis II diagnoses?

Their prevalence is also difficult to estimate. Some studies have demonstrated that transgender individuals may be at increased risk for psychosis, depression, and HIV infection, and their suicide risk is 9-fold higher than that of the general US population.

 In a large-scale nationwide study of more than 6400 transgender individuals, 41% of respondents reported attempting suicide-a rate that is 25 times higher than that of the general population.

One San Francisco study found the attempted suicide rate among more than 500 transgender persons to be 32% for both MTF and FTM participants. The researchers urged the need for intervention at an early age when their results demonstrated a correlation between this percentage and multiple independent psychosocial insults that typically start in a transgender person’s childhood.

What are the requirements for transgender persons to begin transition-supporting hormone therapy?

As with many questions in this field, the answer to this one has evolved in the past decade. In the past, criteria for hormone use included consistent real-life experience as the desired gender for 3 to 12 months, psychiatric evaluation, and psychotherapy for 3 months or longer.

Criteria for hormone therapy, according to WPATH Standard of Care (SOC) version 7, require evaluation and referral by a mental health provider who has observed persistent and well-documented gender dysphoria; capacity to consent for treatment; demonstrable knowledge of the risks, benefits, and limitations of hormone therapy; age of majority in a given country; and otherwise stable, well-controlled medical and mental health.

 These criteria are flexible clinical guidelines for which individual consideration is taken, and fulfillment of one or more criteria may be waived in certain patients, such as those for whom prescribed hormones are expected to help control symptoms of comorbid psychiatric illness or prevent use of illegal and uncontrolled hormones.

The newest approach, the informed consent model, has been adopted by medical providers throughout the world.

 With this model, obtaining informed consent is the first step in starting hormone therapy. This ensures that the patient understands all risks, benefits, psychosocial implications, and limitations of hormone therapy within the context of his or her age, previous experience with hormones, and concurrent medical and mental health concerns. Screening for mental health concerns and the capacity to consent is also incorporated into this model. The main difference between the two protocols is that WPATH SOC recognizes a role for mental health providers throughout the process, whereas the informed consent model encourages the use of mental health services only when requested or when significant impairment is evident, thereby contraindicating the initiation of hormone therapy.

Are there studies that demonstrate evidence of neuroanatomical differences between transpersons and nontranspersons?

The transgender community and many scholars advocate for the declassification of GID as a psychiatric disorder. Studies of the past 15 years have demonstrated that many transgender individuals share certain brain structure similarities, such as shape, size, and density, with their targeted-sex counterparts.

 These studies have especially implicated limbic nuclei, such as the bed 

 of the stria terminalis, as a major source of the body-gender identity discordance felt by transgender individuals.

 Observations of this nature have been appreciated outside of the influence of exogenous hormones and gender-affirming surgery. Hence, the notion that gender dysphoria is a product of a neuroanatomical congenital anomaly is developing and being further explored.

Do exogenous hormones exacerbate mood swings?

In your outpatient practice, you have been caring for a 34-year-old transman who has been stable while receiving testosterone for 2 years. He calls your office in distress, complaining of recent episodes of agitation and mood lability. He worriedly asks if the symptoms are related to his prescribed hormone regimen. How do you approach his question?

No systematic studies have been performed to answer this question. However, clinical experience demonstrates that adverse reactions, especially related to mood, are more likely to occur during the initiation of hormone therapy. Transwomen who start a regimen that includes estrogen may demonstrate symptoms of increased mood reactivity. Similarly, transmen who begin testosterone therapy may experience increased energy and psychomotor agitation. After initiation, hormones are titrated to achieve physiological levels of the target gender, and they are regularly measured to ensure maintenance within the appropriate physiological ranges of either testosterone (320 to 1000 ng/dL) or premenopausal estradiol (less than 200 pg/mL).

 In our experience, when hormone levels are within physiological range, adverse psychiatric symptoms are generally mild and far outweighed by the hormone’s positive gender-affirming effects and resulting mood stability. When hormones reach supraphysiological levels, they are more likely to contribute significantly to psychiatric symptoms.

How is gender dysphoria in childhood treated? What recommendations currently exist?

In children and adolescents, the degree to which timing, extent, and method are highly individualized contributes to the controversy about the best way to serve this population. There is no “typical” presentation of gender dysphoria, and the threshold at which parents seek help for their child varies. Finally, opinions conflict about the ability of prepubertal children and adolescents to consent to and appreciate the gravity of treatment.

Interventions for adolescents with gender dysphoria can be categorized into 3 subsets

• 	Reversible interventions, such as gonadotropin-releasing hormone analogues, spironolactone, or progestins to delay the physical changes associated with puberty

• 	Partially reversible interventions (eg, hormones), when the goal is to actively masculinize or feminize the body

• 	Irreversible interventions, ie, surgical procedures

Careful evaluation and thought are required when considering all treatment options. It is important to appreciate that delaying medical interventions for adolescents with gender dysphoria is not a neutral action, because the resulting prolonged dysphoria and gender-related discrimination are strongly correlated with exacerbation of psychiatric distress.

When childhood or adolescent gender dysphoria is successfully diagnosed and favorably recognized by the family, the safest and most productive decision regarding timing, method, and extent of transition is a reflection of combined input from the patient, family, and treatment team. Regardless of the decision, mental health professionals should counsel and educate families about options, benefits, and implications. It is also recommended that mental health professionals concentrate on the following 

•	Reducing distress related to gender dysphoria in childhood

• 	Helping families express a nurturing and accepting response

• 	Managing familial uncertainty and anxiety

• 	Facilitating decisions about the extent and context of gender role expression

• 	Encouraging families to communicate openly with teachers and other nonrelative adults in the child’s life

• 	Encouraging exploration of gender expression outside of the gender binary

What are some of the controversies surrounding the GID diagnosis? How will DSM-5 characterize this diagnosis?

Members of WPATH generally agree that inclusion of GID in DSM is stigmatizing and have suggested that it be eradicated from DSM. Insurance coverage for medical, psychiatric, surgical, and endocrinological services, in light of this recommendation, remains a concern.

 Many advocates have proposed removing GID from DSM and retaining it in the ICD-10-CM as a medical diagnosis to maintain a third-party payer pathway for gender-affirming treatment in a stigma-free manner. Another proposed change involves renaming the diagnosis so that the word “disorder” is excluded. Some organizations, such as the UK’s National Health Service, leave the classification of GID ambiguous-“a condition for which medical treatment is appropriate in some cases.”

The DSM-5 Task Force has sought to placate critics who strongly disagree with the stigma associated with the DSM inclusion of GID while creating an avenue by which patients with gender-related distress can access services.

 To this end, it is likely that “gender dysphoria” will replace GID in DSM-5 and that this new diagnosis will adopt much of the same criteria previously outlined for GID.

 The diagnosis will continue to emphasize gender-nonconforming behavior and thoughts but only in the setting of “clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability.”

21 Other major revisions are likely to include expansion of criteria, elimination of sexual-orientation specifiers, and separation of child and adult gender-related dysphoria.

 For ongoing and accurate proposed changes in DSM-5, visit the American Psychiatric Association’s Web page on sexual and gender identity disorders.

Author | Christopher Daley, MD

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Working With Transgender Persons