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The first days of September seemed to be “flooded” with societal news with psychiatric implications. For instance, there was the unprecedented and unanticipated flash flooding in New York, New Jersey, and connected areas as Hurricane Ida made its destructive way from Louisiana out to sea again. On the other end of the country, the wildfire approaching Lake Tahoe is still not under enough control.

Then, of course, the startling news that the Supreme Court will not engage or comment on the new ban on abortions in Texas. (As strangely connected as it may seem, the Women’s Mental Health Conference scheduled for Dubai from February 6-9, 2022, was just cancelled because of the COVID-19 pandemic uncertainties.) As far as I know, there are no mental health exceptions to these new abortion restrictions. At least these were available during my residency training in the fall of 1972 when I screened pregnant women—and I approved all requests for such exceptions for abortion due to mental health risk.

 have been trying to keep up with such news with our once-a-week brief Psychiatry & Society videos that are released each Wednesday, as well as other periodic postings, including the poems of 

. With all that is going on, however, it seems like that is not enough. Thus, we will be trying out an additional series, brief written pieces on society and psychiatry on Mondays, Tuesdays, Thursdays, and Fridays. Such is the unique blessing of psychiatry that we can apply our knowledge to so many events in life.

Look for these columns to begin next week, following the unusual confluence of Labor Day in the United States and the first night of Rosh Hashanah. Interestingly, although Rosh Hashanah is the Jewish New Year and the beginning of our High Holy Days, it is also thought to be the celebration of the beginning of the world. In other words, it is really a global ecological anniversary. What this confluence may be telling us is that we have our work cut out for us to make the world a better place. Meeting some of the goals of Rosh Hashanah—forgiveness, social justice, and turning to our best selves—can provide hope that we can ultimately succeed in this challenge.

Comments and suggestions on this and future columns are welcomed and will be shared with Dr Moffic. Please email us at PTEditor@mmhgroup.com.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

In this new series, you will find reflections on psychiatry and society as seen in—and inspired by—current events. 

When We’re Flooded With News

The enactment of Texas law SB8 can have deleterious impact to the health of women seeking care. Furthermore, this law, in my opinion, has the potential to fracture the physician-patient relationship. Women have, and should have, the right to be educated about their medical options in order to make an informed decision regarding their health.

I hope that we consider the mental health implications—increased anxiety, poor self-esteem, and depression—for women who are denied access to abortion, irrespective of the different perspectives on this controversial topic.

Hopefully this poem provides some food for thought.

is associate professor at the University of South Carolina School of Medicine - Greenville and medical director and division chief for Adult Inpatient and Consult-Liaison Services for the Department of Psychiatry and Behavioral Medicine at Prisma Health - Upstate. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

The newest law in Texas dictating women's health brings with it many issues for consideration. 

Reflections on Women’s Health 

The 9 months of pregnancy evoke a multitude of emotions for the mother carrying the "angelic parasite". Expectant mothers are mindful that morning sickness is quite common, but it does not deter them from keeping their eye on the prize. However, intractable vomiting during pregnancy, also known as 

(HG) is a condition that can have deleterious psychological and physiological effects in the form of depression, anxiety, significant weight loss (>5% of original body weight), and dehydration.

I have witnessed firsthand the impact HG can have on a mother’s well-being. My wife, Jennifer, experienced this condition all throughout her pregnancy. As a spouse, I attempted to comfort her as best I could but, at times, felt helpless. During the pregnancy she lost more than 30 pounds, and she required several hospitalizations. It was difficult, at moments, to find any silver linings that would help alleviate fears we had about her quality of life and the angelic parasite in her womb. Thankfully, with the help of a multidisciplinary medical team and a support system consisting of family and friends, my wife’s health improved. The ability to take a shower, brush her teeth, and enjoy a sip of water was rejuvenating.

Our daughter, Claire, now 2.5 years old, was born without any complications. She is the blessing that keeps on giving. It is important to remember that not everyone has a happy ending in the case of HG. This population is often stigmatized due to practitioner bias and skepticism regarding severity of symptoms. I encourage the medical community to realize the gravity of this condition, which is associated with increase rates of termination of pregnancy and suicidal ideation.

I have written a poem dedicated to my wife and all the women who have experienced hyperemesis gravidarum. I hope and pray that it fosters reflection.

White porcelain welcomes two feeble disturbed patellae into their familiar position.

Exhausted cranium searches her way toward the bowl that yeans for a day without chartreuse liquid.

Listless larynx sighs to the angelic parasite: 3 months

White porcelain welcomes mammoth tears that plead for comic relief while in the wilderness.

Calloused stained appendages engulf a seat pleading for casual gluteal conversation.

Delirious heart sighs to the angelic parasite: 6 months

White porcelain welcomes famished countenance that no longer sees its reflection.

Nauseated hair follicles produce repugnance that penetrates the deflated soul.

Malnourished colors skeletons sighs to the angelic parasite: 9 months.

A personal reflection on the psychological impact of hyperemesis gravidarum. 

Hyperemesis Gravidarum: Ode to Its Psychological Impact 

SPECIAL REPORT: SEXUAL AND GENDER MINORITIES PART 2

Fertility considerations in the context of gender-affirming medical care for transgender and nonbinary (TNB) youth have garnered increasing attention in recent years, given the potential for treatments affecting fertility and the expanding availability of fertility preservation 

 The World Professional Association for Transgender Health and the Endocrine Society recommend fertility counseling, including discussions about fertility preservation, as part of the informed consent process for treatment with pubertal suppression and 

 Despite these recommendations, there is little direct guidance about fertility counseling for clinicians. Reported rates of fertility preservation among TNB youth in the United States remains low, ranging from 2.7% to 4.7%, in contrast to relatively higher rates of TNB youth reporting the desire to have genetically related children (

There is no consensus among TNB youth and their families regarding who is best positioned to provide fertility counseling in the context of initiating gender-affirming medical 

 In one study, many families identified the physician prescribing hormones as potentially the most knowledgeable about the effects of puberty suppression and GAH on fertility, but mental health clinicians were also highlighted as key individuals who can help TNB youth explore their attitudes and values related to fertility and family planning and support youth and their families in treatment decision-making.

Given that interdisciplinary care, including mental health clinicians, is recommended for TNB minors seeking gender-affirming medical interventions, psychiatrists and other mental health clinicians are uniquely positioned to participate in the fertility counseling process. Yet, many mental health clinicians report they lack an understanding of the fertility implications of gender-affirming hormonal care, which interferes with their ability to effectively counsel their 

Pubertal Suppression and Gender-Affirming Hormones

Gender-affirming medical interventions are offered to TNB youth based on their age, pubertal stage, and treatment goals. TNB youth in the early stages of puberty may be prescribed gonadotropin-releasing hormone analogues (GnRHa) for pubertal suppression. GnRHa prevent unwanted secondary sex characteristics by suspending pubertal development through suppression of the hypothalamic-pituitary-gonadal axis. This prevents endogenous gonadal sex hormone production. If GnRHa are discontinued, the hypothalamic-pituitary-gonadal axis reactivates, and endogenous puberty progresses.

GnRHa have been used in other populations (eg, children with precocious puberty) with no known fertility impairment. Pubertal development, however, is necessary for sperm production and egg maturation, and it is typically not until the later stages of puberty that mature sperm and eggs are present.

 Thus, TNB youth receiving GnRHa in early puberty, as recommended by current standards of care, will likely not have mature gametes at the time of GnRHa treatment initiation.

 This is important because the vast majority of TNB youth receiving pubertal suppression treatment do not discontinue treatment before starting 

 There is no research examining long-term fertility outcomes in TNB individuals who are treated with GnRHa in early puberty and then go on to initiate GAH, and thus, do not progress in their endogenous puberty. In this population, clinicians cannot predict fertility potential, either naturally or with assisted reproductive technologies.

TNB adolescents presenting for care in later puberty may be prescribed GAH to induce secondary sex characteristics aligned with their gender identity, such as testosterone-mediated changes like facial hair and voice deepening and estrogen-mediated changes like breast development. Research on the effects of GAH on fertility in late pubertal or postpubertal TNB youth is mixed. Study results of transgender men treated with testosterone showed changes in ovarian histology, including stromal hyperplasia, increased collagenization, and morphology consistent with polycystic ovarian syndrome.

 However, implications of these changes on actual fertility and live birth rates are unclear. Case reports have shown transgender men (average age, 28.3 years ± 6.7 years) who discontinued testosterone treatment after an average of 44 months (SD = 31 months) prior to undergoing ovarian stimulation for egg retrieval had a similar number of oocytes retrieved compared with 

 Furthermore, there are several reported cases of transgender men experiencing unplanned pregnancy while taking testosterone, suggesting that ovulation is possible even when menses is suppressed.

 Results from a recent case study also suggest ovarian stimulation for oocyte retrieval without discontinuing testosterone therapy may be possible.

Research shows that estrogen exposure can impair spermatogenesis, although long-term studies in TNB populations have been limited. Among cisgender men, studies of estrogen-secreting tumors show that sperm production is possible after tumor removal, even months to years after abnormal hormone function, whereas results of studies of high-dose estrogen to treat prostate disease show associations with azoospermia and testicular atrophy, with variable reversibility.

 Research among transgender women has shown a reduction in testicular volumes and damage to sperm production after initiating estrogen therapy. However, it remains unclear whether these semen parameters improve after discontinuing 

A range of fertility preservation interventions is available to TNB individuals depending on designated sex at birth and pubertal stage.

 For TNB individuals designated male at birth, sperm cryopreservation is a safe, established, and cost-effective fertility preservation method. Although noninvasive retrieval methods are typically recommended (ie, masturbation), sperm may also be retrieved surgically among individuals for whom masturbation is not desired due to 

 Oocyte and embryo cryopreservation are established options for postmenarcheal TNB individuals. Egg retrieval requires approximately 2 weeks of daily hormone injections to stimulate follicular development, transvaginal or abdominal ultrasounds monitoring, and transvaginal oocyte collection conducted under conscious sedation.

Mature gametes are not usually present before mid to late puberty. In cases in which fertility preservation may be desired before gamete maturation or when gamete maturation is not expected due to GnRHa treatment in early puberty, cryopreservation of immature gonadal tissue may be an option under an experimental institutional review board protocol. However, these options must be discussed carefully with families of minors, given that no live human births have been reported with testicular tissue, and removal of an ovary has implications for future fertility. Further, immature gonadal tissue cryopreservation with consecutive in vitro maturation has some demonstrated success in animal models but has yet to be proven in humans.

“Peyton,” a 15-year-old transgender boy, presents to an interdisciplinary gender health clinic with his parents to discuss starting testosterone. Peyton experienced worsening gender dysphoria as he began menstruating. Peyton and his parents are well informed about the effects of testosterone, including that its effects on future fertility are somewhat unclear and understudied. During the clinic visit, the team introduces fertility preservation as an option. Peyton responds, “I’m not interested in preserving my fertility. I don’t think I want kids and I know I never want to be pregnant, so I’ll just adopt if I change my mind about kids in the future.”

“Ashley,” a 16-year-old transgender girl, has received care at a gender health clinic for the past 6 months. She initiated care with her parents to discuss estrogen therapy for gender affirmation. Ashley’s parents have refused to consent for estrogen unless she agrees to complete sperm cryopreservation before starting hormones. Ashley tearfully shares with the team, “I just don’t think I can give a semen sample. I’m so uncomfortable in my body.”

Fertility counseling for TNB youth is complex for a number of reasons (

). To provide comprehensive fertility counseling across the treatment continuum, psychiatrists and other mental health clinicians caring for TNB youth must be aware of the known and unknown effects of gender-affirming medical interventions on fertility, various fertility preservation options, and new developments in reproductive technology.

Given the known and unknown effects of pubertal suppression and GAH on fertility, counseling is recommended preceding treatment and. Because fertility preservation is possible even after starting gender-affirming medical interventions, counseling should continue on an ongoing basis thereafter. Initial counseling should focus on the effects of GnRHa on gametogenesis and the effects of GAH on fertility because most youth starting GnRHa progress on to GAH. Issues like the potential effects of hormones on fertility and the reversibility of any fertility impairment if hormones are discontinued should be discussed prior to initiating testosterone or estrogen. Because fertility impairment is not absolute with GAH, the need for contraception to prevent undesired pregnancy should also be highlighted. Importantly, TNB youth and families should be informed that there have been no prospective studies examining the effects of long-term (ie, started in adolescence) GAH use on fertility or in those treated with GnRHa in early puberty followed by GAH.

Counseling about fertility preservation should include a comprehensive discussion of what options exist; what each option entails (eg, potential risks, the process for obtaining mature gametes, what is needed to use preserved gametes in the future, cost); the timeframe for completing fertility preservation in the context of gender-affirming medical care; and how long GAH will need to be discontinued to pursue fertility preservation (which can be widely variable) in the case that someone has already started GAH. Potential risks and adverse effects may be physical (eg, ovarian hyperstimulation syndrome) or psychological (eg, potential worsening of gender dysphoria) in nature, and both are equally important to consider. Furthermore, it is important for TNB youth considering fertility preservation to understand the likelihood of a future live birth given the number of mature oocytes or amount of semen obtained, as completing fertility preservation does not guarantee genetically related children. Also, given research showing that over 50% of adult TNB individuals desire children, introducing the possibility that a youth’s current parenthood desires may change over time is also a crucial aspect of fertility counseling.

In summary, fertility discussions should occur within medical and mental health visits with TNB youth, both early and ongoing. Psychiatrists and other mental health clinicians are uniquely positioned to counsel TNB youth and their families about fertility, with particular attention to developmental considerations, navigating complex discussions when parents and youth disagree, and future planning, including exploring the possibility of future infertility-related regret. Individual, family, and cultural factors should be considered, with the ultimate goal of empowering TNB youth to make informed decisions and minimize future regret.

is a pediatric psychologist in the Pritzker Department of Psychiatry and Behavioral Health and director of Behavioral Health in the Potocsnak Family Division of Adolescent & Young Adult Medicine at the Ann & Robert H. Lurie Children’s Hospital of Chicago. She is also associate professor of Psychiatry and Behavioral Sciences, and Pediatrics, at Northwestern University Feinberg School of Medicine. 

 is a pediatric endocrinologist at Nationwide Children’s Hospital and associate professor of Clinical Pediatrics at the Ohio State University College of Medicine. She is also principal investigator at the Center for Biobehavioral Health in the Abigail Wexner Research Institute.

1. Nahata L, Chen D, Moravek MB, et al. Understudied and under-reported: fertility issues in transgender youth-a narrative review. J Pediatr. 2019;205:265-271. 

2. Finlayson C, Johnson EK, Chen D, et al. Proceedings of the working group session on fertility preservation for individuals with gender and sex diversity. Transgend Health. 2016;1(1):99-107.

3. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13(4):165-232.

4. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.

5. Chen D, Simons L, Johnson EK, et al. Fertility preservation for transgender adolescents. J Adolesc Health. 2017;61(1):120-123.

6. Nahata L, Tishelman AC, Caltabellotta NM, Quinn GP. Low fertility preservation utilization among transgender youth. J Adolesc Health. 2017;61(1):40-44.

7. Wakefield BW, Boguszewski KE, Cheney D, Taylor JF. Patterns of fertility discussions and referrals for youth at an interdisciplinary gender clinic. LGBT Health. 2019;6(8):417-421.

8. Strang JF, Jarin J, Call D, et al. Transgender youth fertility attitudes questionnaire: measure development in nonautistic and autistic transgender youth and their parents. J Adolesc Health. 2018;62(2):128-135.

9. Chen D, Matson M, Macapagal K, et al. Attitudes toward fertility and reproductive health among transgender and gender-nonconforming adolescents. J Adolesc Health. 2018;63(1):62-68.

10. Quain KM, Kyweluk MA, Sajwani A, et al. Timing and delivery of fertility preservation information to transgender adolescents, young adults, and their parents. J Adolesc Health. 2021;68(3):619-622. 

11. Chen D, Kolbuck VD, Sutter ME, et al. Knowledge, practice behaviors, and perceived barriers to fertility care among providers of transgender healthcare. J Adolesc Health. 2019;64(2):226-234.

12. Tishelman AC, Sutter ME, Chen D, et al. Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey. J Assist Reprod Genet. 2019;36(3):579-588.

13. Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of adolescents treated with gonadotropin-releasing hormone analogues for gender dysphoria. Arch Sex Behav. 2020;49(7):2611-2618.

14. Leung A, Sakkas D, Pang S, et al N. Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertil Steril. 2019;112(5):858-865.

15. Light A, Wang LF, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception. 2018;98(4):266-269.

16. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120-1127.

17. Gale J, Magee B, Forsyth-Greig A, et al. Oocyte cryopreservation in a transgender man on long term testosterone therapy: a case report. F&S Reports. Published online February 20, 2021.

18. Barnard EP, Dhar CP, Rothenberg SS, et al. Fertility preservation outcomes in adolescent and young adult feminizing transgender patients. Pediatrics. 2019;144(3):e20183943.

19. Jiang DD, Swenson E, Mason M, et al. Effects of estrogen on spermatogenesis in transgender women. Urology. 2019;132:117-122.

20. Johnson EK, Finlayson C. Preservation of fertility potential for gender and sex diverse individuals. Transgend Health. 2016;1(1):41-44. ❒

Psychiatrists should discuss fertility with TNB youth during medical and mental health visits—early and often.

Fertility Considerations for Transgender and Nonbinary Youth: Opportunities for Psychiatrists

June is National Men’s Health Month, and of course that includes men’s mental health too. Unfortunately, men often neglect their mental health, leading to substance abuse, violence, and other harmful behaviors.

In this Mental Health Minute, Russell Kennedy, MD, talks about why men avoid seeking treatment and what psychiatrists can do to help them when they finally walk through the office door.

is a physician specializing in the treatment of 

Anxiety Rx: A New Prescription for Anxiety Relief from the Doctor Who Created It.

How do you help men with anxiety disorders and other psychiatric conditions? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

During National Men’s Health Month, take time to consider the unique mental health needs of male patients.   

What Can Be Done About Anxious and Violent Men? 

June is National Men’s Health Month, a good time to consider the unique mental health needs of men. In this edition of 

, Jonathan E. Alpert, MD, PhD discusses mood disorders and the surprising symptoms that male patients may present.

In this conversation, Alpert also covers:

1. The etiology of major depressive disorder in men and women

2. Common comorbidities to depression among men

3. How to build a therapeutic alliance with men and encourage adherence

4. Effective pharmacological and psychotherapeutic interventions for men and women

5. Future directions for scientific research on mood disorders, including their connections to autoimmune, cardiac, and thyroid conditions.

is the Dorothy and Marty Silverman Chair in in the department of Psychiatry and Behavioral Science, and professor of psychiatry, neuroscience, and pediatrics at Montefiore Medical Center and Albert Einstein College of Medicine.

Although depression is more prevalent among women, it may be more challenging to diagnose in men. This National Men’s Health Month, learn to recognize male depression’s symptoms and catch its comorbidities.  

What Makes Men’s Depression Different? 

In this Mental Health Minute, Jasmin Zapata, MD, discusses young women’s mental health and encourages clinicians to engage with the community—outside of medical settings—to promote good mental health.

books, a series offering mental health guidance to young women and girls.

How do you support young women’s mental health? 

Health outcomes are often determined by factors outside of the hospital and clinic. How can psychiatrists address mental health challenges before they become emergencies?  

Is it Time to Leave the Doctor’s Office? 

Pride is often what drives people to their successes in life. The feeling is associated with a job well done and has been considered an important part of preventing burnout, especially in difficult situations. Since March 2020, headlines around the world have conveyed the sense of pride frontline health care workers, although tired and weary, have felt as they tackled 

. It helped motivate them day in and day out, despite the challenges, to bravely help so many who were affected by the virus.

Psychiatrists, too, have much to be proud about. The field was among the first to 

 visits, ensuring the mental and physical well-being their patients. Similarly, clinicians shed light on the need for interactions to combat loneliness associated with quarantining as well as the importance of self-care for all health care professionals, as evidenced by many articles on our website and in the pages of 

In addition, psychiatry is stepping in to address the chronic pain epidemic. Almost half of the adult US population experienced pain on some days, and about one-fifth had pain most days or every day, 

 by the Centers for Disease Control and Prevention. The number is staggering, and research indicates pain has played a role in the country’s devastating opioid epidemic.

 has addressed pain to keep readers up to date. In this issue, Paul Noufi, MD, and Maryland Pao, MD, further explore the role of consultation-liaison psychiatry and how it can be used to benefit patients who have pain. With this important integrative approach, the authors conclude that, overall, the future looks bright.

Also within these pages, John J. Miller, MD, delves into a discussion on 

. In his monthly editorial, Miller lays the foundation and history of the field and how it affects psychiatry. From there, Harold J. Bursztajn, MD, and colleagues explore the role of epigenetics in resilience and examine the transgenerational transmission of resilience following trauma in this month’s continuing education article. Psychiatry can take pride in these efforts to leverage genetics and epigenetics as a means to prevent and treat psychiatric disorders.

June is also LGBTQ Pride Month, which commemorates the 

 in Manhattan, New York. Along with celebrations, the month presents an opportunity to address the wider social implications. 

 features the second part of our Special Report on sexual and gender minorities (SGM). The collection wraps up this month with an important discussion on the mental health implications of fertility options and trauma-focused cognitive-behavioral therapy for SGM youth.

Much more can be found in this issue, including thought-provoking commentaries and clinical insights from new and regular contributors. We hope you find these articles interesting, entertaining, and informative. As always, we take pride in providing the top-quality information you need to support you, your practice, and your patients. ❒

Pride: A Driving Force

LGBTQ COMMITTEE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

As the number of COVID-19 cases in the United States hits 30 million and continues to cause widespread pain in lives lost and economic devastation, sexual and gender minority youth face particular hardships threatening their lives, mental health, and social development.

In particular, social isolation may be especially challenging. These youths may be quarantining with rejecting family-members and losing contact with supportive social networks. The nature of quarantining means these problems are invisible to the public.

“Aiden,” a 16-year-old boy who is transgender, lives in a community particularly hard-hit by COVID-19. Aiden’s parents refuse to accept his gender identity or call him by his male name or use male pronouns. They frequently yell at Aiden to dress and act like a girl, assigning dishwashing and laundry chores to him alone, and not to his brother, to get him “used to doing girl stuff like you are supposed to.”

Serial COVID-19 outbreaks at Aiden’s school forced him into remote learning. His family has only 1 computer, shared by Aiden and his brother for schoolwork and Aiden’s mother for church meetings. Aiden’s parents banned him from using social media or communicating with friends because his parents believe “that’s where she picked up all this nonsense.” Aiden became completely disconnected from his friends. He was also cut off from affirming and supportive teachers. As tensions in Aiden’s family escalated, fighting became the only interaction between him and his parents.

One evening during a fierce argument, Aiden’s mother pushed him, and he pushed her back. As a result, she fell and had a small laceration on her shoulder. Aiden’s father became angry and punched Aiden in the face. Aiden’s brother called 911. The police arrested Aiden and his father. Aiden was released from jail to a Child Protective Services emergency residence. Because of COVID-19, he was required to spend 14 days isolated in his room, including mealtimes, and was unable to receive visitors. He also faced misdemeanor charges for assaulting his mother. His father also faced charges. Aiden was afraid of returning home because he was petrified of what his father might do to him.

Administration for Children’s Services (ACS) attempted to reunify Aiden with his parents, but over a period of several months, each attempt resulted in further physical altercations between Aiden and his father. Aiden moved into a group home where peers bullied him because of his gender identity. ACS was unable to address the problem because several staff members were hospitalized with COVID-19, and no other group homes were available for transfer. After a bully hit him, Aiden ran away from the group home, and the police could not locate him.

Even before COVID-19, lesbian, gay, bisexual, transgender, questioning (LGBTQ) youth were at 

 of depression, suicidality, and tobacco, alcohol, and other drug use.

 These increased risks stem from elevated rates of rejection, discrimination, and victimization. During the pandemic, risks were further compounded by the loss of relationships in schools, clubs, or other community venues where LGBTQ youth found support and affirmation. Laura Erickson-Schroth, MD, a psychiatrist at the Hetrick-Martin Institute, a New York City-based LGBTQ youth organization, reported that youth members of the institute are looking for more frequent counseling sessions. According to her, there were at least one-third more requests for initial psychiatry visits during 2020 than during the same period in 2019.

 found one-third of the city’s youth in foster care identifies as LGBTQ, an order of magnitude greater than the general population.

 Nearly three-quarters of these youth are Black, and one-third identify as Hispanic/Latino. LGBTQ youth are placed in group homes and other campus settings rather than foster families more often than their non-LGBTQ peers, and they are more likely to be dissatisfied with their placement. The study also found these youth experience a greater burden of depression.

According to Dylan Waguespack, director of public policy and external affairs of 

, 20% to 40% of homeless youth identify as LGBTQ. True Colors United is a national organization dedicated to ending LGBTQ youth homelessness. Although family conflict, involvement in the foster care system, and involvement in the criminal justice system are among the factors that contribute to homelessness among these youth, poverty is often the root cause. Not only are these youth at risk for adverse mental health outcomes because of rejection and discriminatory behaviors, they often face traumatic experiences through conflict with their families, involvement in overwhelmed and poorly informed state programs.

Agencies that previously made efforts to address racial, social, gender, or sexuality based inequities before the pandemic have become even more overwhelmed with the increase in housing and food insecurity, increased unemployment, instability in the agency’s own staff, and the need to rapidly implement physical distancing and other public health measures in routine work. Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications.

Even as the pandemic ends, there may be continual struggles and support needs. Fortunately, there are ways psychiatrists and other mental health care professions can help.

Some of these methods include the following:

Financially donate to organizations that support or serve LGBTQ youth.

Advocate for programs that decrease income inequality and promote housing and food security.

Enable rapid interventions to prevent LGBTQ youth from entering the foster care and criminal justice systems.

Use clinical, teaching, institutional, and forensic roles to speak out and advocate for this vulnerable group of young people.

Share resources and references for supportive organizations with patients who are LGBTQ (

LGBTQ youth have long experienced marginalization and significantly increased risk of poor mental health outcomes. The COVID-19 pandemic sharpened the crisis and brought clarity to the precariousness of social service agencies that address those needs. Strengthening the support system for these youth and their allies and making agencies more inclusive of their voices is critical to help these young people achieve a healthy and fulfilling life.

is the director of the Youth Equity Science/YES Project and senior visiting fellow at Yale Law School. He is also an assistant clinical professor at Columbia University and an adjunct clinical assistant professor at Cornell Weill Medical College.

the medical director emeritus at Weill Cornell Center for Human Rights. Dr Barberis the past president and journal editor for the Association of LGBTQ Psychiatrists and is an MDiv candidate at Union Theological Seminary.

is a community and public psychiatrist in New York City.Dr Drescher is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. He is also a distinguished life fellow of the American Psychological Association and the past president of the Group for Advancement of Psychiatry

is an assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at Hetrick-Martin Institute for LGBTQ youth.

. 2020;18(3):268-276. doi:10.1176.appi.focus.20200018
2. Sandfort TGM. Experiences and well-being of sexual and gender diverse youth in foster care in New York City: disproportionality and disparities. November 2020. Accessed January 5, 2020. 

https://www1.nyc.gov/assets/acs/pdf/about/2020/WellBeingStudyLGBTQ.pdf

Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications. There are 5 ways psychiatrists can help.

Helping LGBTQ Youth During the Pandemic

The impact of the COVID-19 pandemic on women around the world has been both troubling and illuminating. Record numbers of women have had to drop out of the workforce, and 

 There has been a 25 to 300%increase in reported cases of domestic violence against women

 Although death and hospitalization rates related to the pandemic have been higher for men than women, the COVID-19 brain health crisis (everything from depression and anxiety to neurological disorders like Alzheimer disease) has disproportionately affected women. What are the reasons underlying this inequity, known as the “The Brain Gap”? What are the impacts on children, families, communities, and future generations?

Closing the gap will require a comprehensive and systematic approach to the addressing gender equality. Getting more women in research and health care is a good first step, but it is not nearly enough. To improve women’s mental health, we must incorporate new data: namely, the perspective and experience of women. Solutions that consider the experience of women are more likely to create structural change across sectors, from neuroscience and health care to racial equality, public policy, and workplace norms.

Biological, sociocultural, and economic factors are relevant to understanding and promoting gender health, and to elucidating and reducing gender disparities. At the most fundamental level, neuroscience and clinical research have not sufficiently incorporated sex and gender-based differences into their understandings the disease development, or the subsequent treatment considerations. Accounting for sex and gender differences is a must if we want to move from a one-size-fits-all medical model towards precision medicine, where big data and artificial intelligence may enable personalized solutions.

For example, as of 2019, Alzheimer disease and other forms of dementia are the 7th leading cause of death globally, with women accounting for 

 Unfolding research demonstrates that current strategies to address the ever-growing care burden and cost of dementias have not adequately considered sex and gender differences in the molecular presentations of the illness.

 Nor have they considered the gender-specific biological and socio-cultural risk factors, rates of disease progression, or considerations for community management to ensure equity in care.

The interactions with the reproductive system are crucial for brain health and aging in women. Menopause, surgical menopause, preeclampsia, higher rates of depression, primary caregiving, and lower education levels are risk factors for developing dementia.

 These findings, however, have not changed the way we contextualize and treat these conditions. Decreasing levels of estrogen in perimenopause can contribute to issues with cognitive performance that sometimes resolve post-menopause, but have also been found to increase rates of dementia-related cognitive decline.

 Such insights can influence the way we tailor and prescribe treatments to women with Alzheimer disease.

The conversation about women’s equality must not be limited to cisgender white females. Because brain health disparities are exacerbated in racial-ethnic minorities and other underserved and marginalized groups, accounting for the impacts of interpersonal violence, racism, casteism, poverty, trans and homophobia is the only way to truly achieve gender equality and, ultimately, economic and social prosperity. For example, posttraumatic stress disorder (PTSD) was originally considered to be an illness of combat veterans, but it is much more likely to develop in women as a result of sexual assault and intimate partner violence.

 The latter is unfortunately highly prevalent in minoritized communities, and studies have shown that women of color and of lower socioeconomic status have very high rates of PTSD.

 These discrepancies exist for other mental illnesses and syndromes, including depression, anxiety, attention-deficit/hyperactivity disorder, substance use disorders, migraine, and trauma-related disorders.

 Such insights must be taken into account in next generation health care solutions for women.

Research institutions are calling for the inclusion of a more diverse array of women in preclinical development and in clinical trials, and the expansion of research design to focus on culturally relevant experiences in order to collect more 

 Furthermore, in order to translate this data into action, we must promote female leadership in health care and public health efforts. Although the majority of the long-term care workforce is female and the majority of residents in nursing homes are women, women remain underrepresented in health care leadership, underlining the lack of gendered consideration in 

Unfortunately, while the number of women employed and promoted in the workplace had been slowly trending up prior to the pandemic, COVID-19 may have halted that 

 In the United States, more than 2.2 million women have dropped out of the labor force in the 

 Women of color have been disproportionately laid off or furloughed, while others have had to tend to caregiving and primary provider responsibilities at home.

Unfortunately, these trends will have lasting consequences. For example, markers of scientific productivity decreased by 30% for women during the pandemic, whereas productivity for men 

 This could significantly set women back from professional growth for the next decade. Moreover, in the business sector, 

 found that “This is not just a ‘she-cession,’ but a devastating loss of contributions.”

 Women who voluntarily left their work reported burnout and difficulty balancing work and personal responsibilities. In the study, 70% disclosed they do most of the cooking, household shopping, and cleaning, and 80% of women who plan to reenter the workforce are concerned about limited economic opportunities and obtaining jobs that do not take full advantage of their training and skillsets. These concerns have led to a push for expanded childcare options, paid time off or medical leave; government-approved stimulus packages for childcare providers. In addition, there should be support for flexibility for employees who have multiple roles and responsibility in and out of the office. These benefits, however, are not often inclusive of the most marginalized groups, who are overrepresented in sectors that require face-to-face interactions, forcing them to choose between work and domestic care as we continue our work/study-from-home pandemic lifestyle. 

Roles for women at home range from primary caregiver for children, elderly parents and relatives, to chef, housecleaner, therapist, and educator. According to some studies, the wellbeing of women has directly correlated to the wellbeing of their families, from children, to spouses, to parents and extended community.

 A recent study showed that the state of Texas lost $2.2 billion due to untreated maternal mental health issues, not only due to effects on the mother’s productivity and health, but also due to downstream effects on the health and development of the 

 Not surprisingly, untreated mental health conditions occurred in 18.2% of Black women, and 11.4% of non-Hispanic white women, again demonstrating the importance of breaking down the data to accurately reflect the relative impact on marginalized communities.

Despite women’s central role in family wellbeing, domestic violence against women has risen during the pandemic. Prior to the crisis, 1 in 3 women around the globe experienced physical or sexual violence at least once in their 

 Since the onset of the COVID-19 pandemic, there has been a reported surge in the number of calls to violence-against-women-and-girls 

 The United Nations projected that an additional 15 million women could be affected by violence every 3 months of 

 This type of trauma decreases women’s sense of empowerment and self-worth, further burdening women with symptoms of depression, anxiety, and keeping them locked in cycles of oppression.

It is clear that women carry the major weight during times of crises, a point that is becoming even more apparent during the current brain health crises. Solutions that include women are more likely to have success and create structural change across sectors, from neuroscience and health care to racial equality, public policy, and workplace norms.

To that point, evidence indicates that women are more proactive in taking advantage of opportunities to improve, rebound, and strengthen their brain health and resilience, and translate this charge to their families, communities, and the workplace. In a recent telehealth study, women across the lifespan enrolled in the BrainHealth Project (a landmark scientific study to define, measure, and enhance brain health and performance) at 3 times the rate of men.

 The results showed comparable gains between men and women in 3 factors contributing to global brain health: 1) clarity (innovation, reasoning, optimism, compassion), 2) fortitude (emotional balance), and 3) resilience (social support, purpose). These gains were achieved at a time when so many were experiencing heightened depression, anxiety, social isolation, and brain fog. These results suggest that, while women carry the weight during times of crises, they also are ready to build brain health for themselves, their families, and their communities. Giving major attention to the pivotal role of women in boosting economic and societal resilience may help shore up the weakening foundation of our families, communities, and workforces.

To close the brain gap, we must work to identify and quantify the mental health issues facing women, with the goal of identifying data-driven levers for change. These levers can include clinical research and care, policy and process changes, as well as investing in female-identifying entrepreneurs and companies focusing on menopause, fertility, trans health, and postpartum depression. Closing the brain gap will prepare our socioeconomic systems for future shocks and will also make for stronger communities in times of peace. Doing so will require a transdisciplinary effort that is committed to building the infrastructure required to support the diversity of women in society. In order to develop successful solutions, we must work toward better understanding the underlying problems. We cannot afford to do otherwise.

is a psychiatrist with the Massachusetts General Hospital at Harvard Medical School, and co-founder and chief clinical officer of the Brainstorm Lab for Mental Health Innovation at Stanford University.

is advisor to the chief of staff and gender advisor, Office of the Secretary-General, Organisation for Economic Co-operation and Development (OECD)

is special advisor to the OECD secretary general and head of the OECD New Approaches to Economic Challenges Unit.

is an associate with the PRODEO Institute and a Thiel Fellow at Stanford University. 

is director of the Monash Alfred Psychiatry research centre and head of the Central Clinical School Department of Psychiatry at Monash University

The COVID-19 pandemic has exacerbated mental health and gender inequalities around the world. Understanding the causes is the first step toward finding solutions. 

Gender Issues