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Here in Oregon, for environmental reasons, you do not pump your own gas. When you go to a gas station, someone fills your tank for you.

The other day, I was waiting for the attendant to serve me, but he was rather busy flirting with a customer. He started grooming her by saying how much he liked her car, and then he commented on her looks. I could see how uncomfortable she was when he proceeded to insist on getting her number. He did not stop before he made sure she called his cell phone so he could save her contact information.

This is not at all uncommon. Many women get harassed while performing even the simplest of daily tasks that should be risk-free. I made it clear to the attendant that he was intrusive, his behavior was unethical, and he likely had violated her personal boundaries. He brushed me off by saying that I should take it easy. I told his supervisor that such behavior should not be condoned or tolerated, and the supervisor promised me he would talk to him.

The attendant took the woman’s reluctant agreement as a consent, not realizing that in such relationships, there is power inequality and many female customers might indeed not speak up when someone in a position of power takes advantage of their needs.

I think, morally speaking, it is an extremely low act to abuse a position of influence to exploit others. We have heard stories of teachers, doctors, and preachers taking advantage of those entrusted to their care—but as the gas station incident showed me, women are not safe anywhere they go.

It is a communal responsibility to change that. Women need to be empowered to speak up, and men need to speak up for them. It is not enough to roll your eyes or shake your head when you bear witness to such violations. Changing the status quo requires all of us to take an active stand.

In the hospital where I work, we use the acronym “CUS” to encourage staff to speak up. C stands for 

 (“I am really concerned to be observing/hearing this”); U stands for 

 (“this is making me uncomfortable”); and S stands for 

 (“I want you to immediately stop”). And, of course, no one should risk their life or safety when defending others. We have seen people die while standing up against oppression, including the 3 individuals who were stabbed inside a train here in Portland while trying to protect women from a bigot.

I see any female as my mom, wife, sister, or daughter. What I dislike for my loved ones, I dislike for all other women. I am inviting men to take responsibility, to become role models themselves, and to raise their boys to respect and protect women. This cycle needs to be broken.

Women deserve better. They deserve to feel safe inside and outside their homes, at their places of employment, in their houses of worship, and wherever they might be—including my local gas station.

 is a practicing psychiatrist with Providence Healthcare System in Portland, Oregon. He is the author of 

The Wounded Healer: The Pain and Joy of Caregiving

“Changing the status quo requires all of us to take an active stand.”

Our Women Deserve Better

 (BD) affects 1% to 3% of the world’s population and is characterized by alterations in mood, levels of energy, and functioning. Despite these common features, BD includes a group of polymorphic and heterogeneous conditions in terms of clinical presentation, course, response to treatment, and functional outcome.

 Several sociodemographic and clinical variables have been investigated as potential factors influencing the development and course of illness, such as age at onset, employment status, marital status, number of manic/depressive episodes, predominant polarity, and—above all—gender and sex.

There has been a rising interest in gender-related specificities in BD (

However, the presence of clinical and epidemiological distinctions between male and female patients and their role in the diagnostic and therapeutic process is still controversial.

 Sex specificity may affect many variables, including incidence, prevalence, subtypes (BD I and BD II), rapid cycling, suicidal behavior, comorbidities, treatment response, and adverse effects. Moreover, among females, hormonal oscillations related to the menstrual and reproductive cycle may influence the disease and its treatment.

Compelling evidence has documented an almost equal male-female sex ratio in incidence and lifetime BD prevalence rates (

Nonetheless, recent studies suggest an increased frequency of BD diagnosis among women, for both BD I and BD II. Furthermore, hypomania, and consequently BD II subtype, are more frequently associated with female sex.

Although age at first mood episode does not apparently differ between women and men, men more commonly experience a first manic episode during childhood.

 Men more often have a first manic episode, whereas women seem more likely to face a depressive one.

 In addition, being female is more frequently related to depressive recurrences, depressive predominant polarity, and higher lifetime prevalence of psychotic depression.

Women more often report depression and large fluctuations in mood as well as more frequent mood oscillations across the menstrual cycle.

 On this basis, the identification of BD in women may be more challenging, leading to a higher rate of misdiagnosis of major depressive disorder. Indeed, some other characteristics may help clinicians in the successful recognition of BD in women, including lifetime rapid cycling

 The probability of mixed symptoms in females increases consistently with the severity of hypomania but decreases at the most severe levels of hypomania.

Suicide attempt rates have been significantly more frequent among females, even though death by suicide has occurred more commonly in men.

 As a result, physicians should consider the possibility of an unrecognized bipolar diathesis if they see frequent depressive recurrences despite antidepressant therapy, the presence of psychotic features during a depressive episode, and a high number of suicide attempts in women.

Psychiatric and medical comorbidities often negatively affect BD course, regardless of sex. Comorbidity with alcohol and other substance use disorders (eg, cannabis abuse/dependence and pathological gambling) has been more frequently documented among males.

 However, Goodwin and Jamison have suggested a higher prevalence of alcohol abuse among women with BD II.

 Co-occurrence of personality disorders (particularly of cluster B), eating disorders such as bulimia, and posttraumatic stress disorder was generally observed with a higher frequency among females.

 A sex-specific effect has also been illustrated for comorbid obsessive-compulsive disorder (OCD) and anxiety spectrum disorders, with increased OCD rates in males and panic disorder in females. Organic conditions such as migraine, thyroid disorders (especially hypothyroidism), and autoimmune disorders seem to be more commonly associated with female gender in BD.

Previous investigation of sex differences in the most affected domains in BD—including executive function, verbal and visual memory, verbal learning, attention and processing speed—did not identify differing results. However, recent findings showed a better performance in working memory tasks among males, whereas a better performance was found in verbal learning and memory recognition tasks among females.

 Finally, a sex differential emerged in psychosocial functioning, with females with BD tending to report better social and occupational status than their male counterparts.

The correlation between sex/gender and response to pharmacological treatment has been extensively investigated, with a particular focus on mood stabilizers and antipsychotics. Beyond an increased use of antidepressants, women with BD seem to more frequently receive a combination treatment, whereas men have more often reported receiving lithium.

 Considering sex differences in clinical response to lithium, a pooled data analysis outlined response rates of 65.6% in women and 61.0% in men. Another longitudinal study found that, in comparison with men treated with lithium, women treated with lithium had a significantly longer median time to first recurrence.

The use of antipsychotics in BD has increased in past decades, apparently with no differences in their prescription.

 Regarding efficacy, in an 8-week trial of treatment with placebo, olanzapine, or olanzapine/fluoxetine in combination, male patients with depression and manic-predominant polarity experienced higher rates of improvement compared with those with depressive polarity. Among females, no differences in terms of response were observed by means of predominant polarity.

Some authors have hypothesized a correlation between sex and occurrence, intensity, and type of medication adverse effects, thus influencing their prescribing patterns. Regarding lithium, female sex emerged as the main risk factor for the development of hypothyroidism during treatment, especially for women aged 40 to 59 years. Valproate use in females may lead to polycystic ovaries, polycystic ovary syndrome, hyperandrogenism, and obesity. Valproate needs to have an extremely low priority in women of childbearing potential due to the important risks of neurodevelopmental delays and polycystic ovary. However, it can be effective and well tolerated in females not of reproductive potential. Moreover, many typical and some atypical antipsychotics may be associated with hyperprolactinemia, which can result in galactorrhea, amenorrhea, and other menstrual cycle irregularities.

 Although females with BD were generally more adherent to therapeutic indications, they nonetheless seemed to be more concerned about adverse effects like weight gain.

In terms of nonpharmacological strategies, female patients with depression underwent significantly fewer antidepressant drug trials than their male counterparts before being prescribed electroconvulsive therapy. When used in patients with schizophrenia, its effectiveness was greater in females, but this difference was not replicated in individuals with BD, possibly because of the small sample size.

 No evidence supported the notion of a different response to psychotherapy between genders.

Women physiologically experience endogenous fluctuations in ovarian hormone levels, including recurring oscillation of estradiol and progesterone. These fluctuations may affect BD pathophysiology and clinical presentation. It is worth noting that symptoms may worsen when gonadal hormone levels are low, either during the premenstrual phase of the cycle—thus hindering the distinction from premenstrual dysphoric disorder4—and postpartum.

 This period may be burdened by a relevant risk of BD onset and relapse. For instance, a recent meta-analysis found an overall postpartum relapse risk of 37%, with almost a quarter of those suffering from affective psychosis, mania, mixed episodes, or relapses requiring hospitalization, and the remaining patients suffering from nonpsychotic affective episodes, mostly depressive.

 Accordingly, clinical trials suggested that exogenous estrogenic treatments may improve specific symptoms of BD.

During pregnancy, women with BD should undergo close monitoring because of the correlation between BD and pregnancy complications, as well as potential congenital anomalies in infants. The discontinuation of medications may trigger a mood recurrence and thus lead to disruption of daily living functioning, including a patient’s ability to take care of the child.

 By contrast, the teratogenic potential of various mood stabilizers must be kept in mind; lithium may enhance the risk of cardiovascular malformations (such as Ebstein anomaly), and valproate and carbamazepine are both associated with the risk of neural tube defects, including spina bifida. Hence, when treating women with BD who wish to become pregnant, the risk-benefit ratio should be assessed by evaluating the teratogenic risk of pharmacotherapy and the negative impact of untreated BD symptoms on the pregnant woman and the fetus.

The same shrewdness should be promoted in treating women with BD during breastfeeding. Some mood stabilizers, including carbamazepine and valproate, are not contraindicated, whereas lithium is not compatible with lactation. In addition, there is no consensus regarding the use of antipsychotics during pregnancy and breastfeeding.

Finally, during the menopause transition, many women face unspecific mood symptoms. In females with BD, the perimenopausal phase may enhance mood instability, with increased depressive symptoms and reduced manic symptoms.

Some epidemiological and clinical characteristics of BD may differ between the sexes. Although further investigation is encouraged, the preceding preliminary findings may guide practitioners in clinical practice by facilitating BD identification, especially in case of depressive onset, and by orienting treatment interventions, with a special focus on life events related to the female reproductive cycle. The effort should go towards avoiding valproate and carbamazepine in women of child-bearing potential, unless associated with hormonal contraceptives.

is an associate professor of psychiatry at the University of Milan, and director of the psychiatric clinic of the Ospedale Luigi Sacco-Polo Universitario of Milan. He is also a scientific advisor in the Department of Psychiatry and Behavioral Sciences of Stanford University and cochair of the International College of Obsessive Compulsive Spectrum Disorders. 

is a psychiatrist in the Department of Psychiatry, University of Milan. 

 is a resident in psychiatry in the Department of Biomedical and Clinical Sciences of the University of Milan. 

In the last 3 years, Dr Dell’Osso has received lecture honoraria and research grants from Angelini, Lundbeck, Janssen, Pfizer, Otzuka, Neuraxpharm, and Livanova. The other authors have no conflicts to declare.

Is sex important? gender differences in bipolar disorder.

Sex differences in schizophrenia, bipolar disorder, and post-traumatic stress disorder: are gonadal hormones the link?

Has bipolar disorder become a predominantly female gender related condition? analysis of recently published large sample studies.

6. Kennedy N, Boydell J, Kalidindi S, et al. 

Gender differences in incidence and age at onset of mania and bipolar disorder over a 35-year period in Camberwell, England.

7. Altshuler LL, Kupka RW, Hellemann G, et al. 

Gender and depressive symptoms in 711 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Outcome Network.

8. Nivoli AMA, Pacchiarotti I, Rosa AR, et al. 

Gender differences in a cohort study of 604 bipolar patients: the role of predominant polarity.

9. Buoli M, Cesana BM, Dell’osso B, et al. 

Gender-related differences in patients with bipolar disorder: a nationwide study.

Sex-specific self-reported mood changes by patients with bipolar disorder.

11. Schneck CD, Miklowitz DJ, Miyahara S, et al. 

The prospective course of rapid-cycling bipolar disorder: findings from the STEP-BD.

12. Buoli M, Cesana BM, Maina G, et al; ISBD Italian Chapter Epidemiologic Group. 

Correlates of current rapid-cycling bipolar disorder: results from the Italian multicentric RENDiBi study.

Gender differences in the phenomenology of bipolar disorder.

15. Suppes T, Mintz J, McElroy SL, et al. 

Mixed hypomania in 908 patients with bipolar disorder evaluated prospectively in the Stanley Foundation Bipolar Treatment Network: a sex-specific phenomenon.

Gender differences in bipolar disorder: age of onset, course, comorbidity, and symptom presentation.

Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Second Edition

18. Baldassano CF, Marangell LB, Gyulai L, et al. 

Gender differences in bipolar disorder: retrospective data from the first 500 STEP-BD participants.

19. Suominen K, Mantere O, Valtonen H, et al. 

Gender differences in bipolar disorder type I and II.

20. Saunders EFH, Fitzgerald KD, Zhang P, McInnis MG. 

Clinical features of bipolar disorder comorbid with anxiety disorders differ between men and women.

Sex differences in neurocognitive and psychosocial functioning in bipolar disorder.

22. Sanchez-Autet M, Arranz B, Safont G, et al. 

Gender differences in C-reactive protein and homocysteine modulation of cognitive performance and real-world functioning in bipolar disorder.

23. Karanti A, Bobeck C, Osterman M, et al. 

Gender differences in the treatment of patients with bipolar disorder: a study of 7354 patients.

24. Viguera AC, Tondo L, Baldessarini RJ. 

Sex differences in response to lithium treatment.

25. Viguera AC, Baldessarini RJ, Tondo L. 

Response to lithium maintenance treatment in bipolar disorders: comparison of women and men.

Predominant previous polarity as an outcome predictor in a controlled treatment trial for depression in bipolar I disorder patients.

Gender differences in electroconvulsive therapy: a retrospective chart review.

28. Vega P, Barbeito S, Ruiz de Azúa S, et al. 

Bipolar disorder differences between genders: special considerations for women.

29. Wesseloo R, Kamperman AM, Munk-Olsen T, et al. 

Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis.

Bipolar II postpartum depression: detection, diagnosis, and treatment.

What are the differences in epidemiological and clinical characteristics of bipolar disorder between the sexes?

Gender and Sex Issues in Bipolar Disorder

There is increased recognition of sex differences in the epidemiology and phenomenology of 

. For example, compared with males, females have a slightly lower incidence of the disorder, a later age of onset, and more depressive symptoms.

 Such sex differences may be mediated, in part, by the neuroprotective effects of estrogen.

 By contrast, findings regarding sex differences in cognition in schizophrenia are inconsistent.

 Insomnia is also common in the clinical course of schizophrenia.

 In the general population, insomnia is associated with greater cognitive impairment, but its association (and potential sexual dimorphic effect) in schizophrenia is less clear.

“Ms Smith” is a white woman, aged 50 years, with a 20+ year history of schizoaffective disorder, bipolar type, and a remote history of a cerebellar hemorrhagic stroke. She has been on a stable dose of antipsychotic medication for the past 10 years, prior to which a clozapine trial was discontinued due to tolerability and adverse effects. She chronically sleeps 3 to 5 hours per night, with both initial and terminal insomnia. She has chronic auditory hallucinations, thought insertion, and persecutory beliefs. She also has chronic cognitive impairment, thought to be in part due not only to her chronic psychotic illness, but to a sequela of the past cerebellar infarct. She graduated with a 2-year technical degree after high school. She has completed different forms of the Digit Symbol Coding test at multiple outpatient psychiatric clinic visits over the years, with a mean (SD) score of 31±4. A trial of adjunctive electroconvulsive therapy for residual positive symptoms of psychosis was discontinued due to exacerbation of cognitive impairment.

Zhu and colleagues investigated sex differences in insomnia and cognition in a large sample of Chinese patients with chronic schizophrenia.

 They recruited 718 patients (480 males and 238 females) with chronic schizophrenia from 2 psychiatric hospitals, along with 397 healthy controls (169 males and 228 females) without a personal or family history of psychiatric or neurological disease. Inclusion criteria for patients were age 17 to 70 years; Chinese Han ethnicity; DSM-IV diagnosis of schizophrenia; and stable antipsychotic dose for > 6 months. Patients were excluded if they had any of the following: a history of neurological disease or drug or alcohol abuse; current severe medical comorbidity; head injury; or current pregnancy or lactation.

Insomnia was assessed as both a categorical (yes/no) and a continuous measure with the Insomnia Severity Index (ISI). Symptoms were rated using the Positive and Negative Syndrome Scale (PANSS). Cognition was evaluated with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The authors used 2 x 2 ANOVA (insomnia x sex) and Spearman correlation coefficients to investigate sex differences in clinical variables in patients with and without insomnia.

The mean subject age was 46 years. There was a significantly increased prevalence of (categorical) insomnia in females vs males with schizophrenia (25.6% vs 18.3%; OR, 1.54). Females with schizophrenia also had significantly higher PANSS total and subscale scores. Males with schizophrenia had higher (better) RBANS total, visuospatial/constructional, and language scores than females. In both males and females with schizophrenia, patients with (categorical) insomnia had higher PANSS scores than those without insomnia. By contrast, there was no difference in RBANS scores in males with vs without insomnia. However, females with insomnia had lower RBANS total and subscale scores. As a continuous measure, ISI scores were significantly, negatively correlated with RBANS total scores, language, attention, and delayed memory scores in males (P = –.14 to –.12 for each). By contrast, ISI scores were significantly negatively correlated with RBANS total scores (P = –.18) and immediate memory (P = –.19) scores in females.

The authors concluded that females with schizophrenia had an increased prevalence of insomnia and greater cognitive impairment than males. They also found sex differences in correlations between insomnia and cognition in these patients. Study strengths included the large cumulative sample size. Study limitations included the cross-sectional study design and the nonstandardized antipsychotic (and other) medications in the study sample. Future studies should consider associations between insomnia and cognition using a longitudinal design and also in first-episode and antipsychotic-free patients with schizophrenia.

Findings support evidence for sex differences in insomnia and cognition in patients with schizophrenia. Given its association with more severe symptoms and greater cognitive impairment, insomnia represents an important potential treatment target in this patient population.

is a professor in the Department of Psychiatry and Health Behavior of Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

Sex and gender differences in schizophrenic psychoses

Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review

Oestrogens, prolactin, hypothalamic-pituitary-gonadal axis, and schizophrenic psychoses

Prevalence of insomnia and clinical and quality of life correlates in Chinese patients with schizophrenia treated in primary care

Sex difference in association between insomnia and cognitive impairment in patients with chronic schizophrenia

“In the general population, insomnia is associated with greater cognitive impairment, but its association (and potential sexual dimorphic effect) in schizophrenia is less clear.”

Insomnia and Cognition in Males vs Females With Schizophrenia

, we worked with experts from multiple areas in psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, from managing depression in older adults and differences in trauma response to the effects of the COVID-19 pandemic on youth and the growing US mental health crisis. Here are some highlights.

Psychiatric Care in the US: Are We Facing a Crisis?

By the end of 2021, many American adults found themselves inthe worst mental state in years. According to the US Census Bureau’s Household Pulse Survey, 47% of adults reported symptoms of anxiety,

 and 1 in 5 adults disclosed suffering from a mental illness.

 Despite this, it is estimated that less than half of Americans with a mental disorder get adequate treatment.

“It has been just over a year now since the COVID-19 pandemic struck the United States full force. A year of hunkering down and Zooming in, teleworking and telepsychiatry, economic and social upheaval, and steady scientific progress. Looking back to last March, we knew this would be difficult. But we didn’t know how difficult. And we certainly didn’t know that the challenge of COVID-19 would last this long,” said Joshua A. Gordon, MD, PhD, director of the National Institute of Mental Health, in a 2021 director’s message.

Why Men and Women May Respond Differently to Psychological Trauma

Posttraumatic stress disorder (PTSD) is a mental health disorder that arises after experiencing a traumatic event in about 10% of exposed individuals. A hallmark symptom is the reexperiencing of the traumatic event in the form of nightmares or flashbacks or reliving the event upon certain triggers. 

These unwanted memories cannot be controlled, and the event may feel like it is happening again. Individuals with PTSD will try to avoid these memories by not talking about them or by staying away from situations where potential triggers might be present (eg, the store where the robbery took place or watching the news about current combat events or natural disasters).

Several cognitive and mood alterations—such as memory problems, negative thoughts or feelings, and high arousal levels—may manifest themselves in several ways. These include being easily startled and having angry outbursts, sleeping problems, or difficulty concentrating on everyday tasks. 

The Management of Depression Among Older Adults

Depression is not an uncommon condition among older adults, and it is often underdiagnosed in this population. Depression also results in greater rates of morbidity and mortality among older adults. 

The neurobiology of depression includes a complex interaction among various biological, psychological, and social factors. The identification of depression among older adults requires a thorough history, a focused physical examination, appropriate laboratory studies, and the use of neuropsychological testing when necessary.

Current available treatments for older adults with depression include psychotherapy, pharmacotherapy, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and collaborative care approaches.

 In addition, some evidence indicates that aerobic and supervised group exercise regimens may improve depressive symptoms among older adults.

 In this review, we assess the evidence for using psychotherapy, pharmacotherapy, ECT, TMS, and collaborative care approaches for the treatment of depression among older adults. 

Here’s How the COVID-19 Pandemic is Shaping the Next Generation

The full picture of teenagers’ experience of COVID-19 is just beginning to emerge. The school closures, canceled proms, and separation from friends seemed a small price to pay to save the lives of thousands—but in exchange, the adolescents who represent the younger side of Generation Z were robbed of the capstone of their formative years. It created an atmosphere of uncertainty and anxiety among some teens, about both the future and their place in it.

As if the pandemic was not enough, teens watched as police violence and racial tensions reached breaking points. They saw angry mobs take over cities and storm the Capitol. Then Mother Nature swept in with deadly wildfires and other natural disasters that underscored the threat of climate change. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the April 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: April 2022


Although the lack of mental health services available to all youth has been exposed as a result of COVID-19, this is particularly problematic for LGBTQ+ youth.

 Specifically, transgender and gender-diverse (TGD) youth experience higher rates of depression, suicidal behaviors, and self-injury than their cisgender peers (see 

A recent survey of adolescents across the United States indicated that about 2% of middle and high school students identify as transgender or gender diverse,

 a number that has been increasing over time.

 Importantly, although many TGD individuals feel a strong discomfort with their body and change their gender expression and roles and/or physical characteristics to align with their identity, not everyone experiences the distress related to the clinical diagnosis of 

With increased research looking at the experiences of TGD individuals separately from their sexual minority peers, we have begun to better understand cooccurring issues for this distinct population. Specifically, depression, self-injurious behaviors, 

, disordered eating, and anxiety have been reported, as have high suicide attempt rates: These rates are at least 3 times higher than those of cisgender peers.

Why are we now seeing such increased rates of comorbidities with TGD individuals? Proposed by Hendricks and colleagues,

 the Gender Minority Stress and Resilience Model (GMSRM) is a framework through which we can understand the unique internal and external stressors that impact TGD individuals, as well as factors that contribute to resilience. The authors posit that external experiences of discrimination, victimization, rejection, and nonaffirmation of gender identity combine with internalized transphobia, negative expectations of the world and others, and concealment; these leave TGD individuals at risk for the development of negative mental health symptoms such as 

, suicidality, and self-injurious behavior.

Therefore, when working with TGD individuals, we need to assess for the internal mechanisms related to any psychiatric diagnosis, but also the external/environmental factors that are contributing to and maintaining the symptoms. For example, numerous studies have looked at the relationship between invalidation and victimization in schools, hospitals, and therapy that led to individuals dropping out of school, not accessing care, or ending treatment.

 In addition, we must continuously use an intersectional lens to be able to understand how additional identities that have been marginalized (eg, race, ethnicity, sexual orientation, ability, religion) may also be impacting the individual’s functioning, as well as the level of gender dysphoria the individual is experiencing. Attention to all these contributing/maintaining factors—both internal and external—is necessary for the best treatment.

Consider this metaphor: If you have to put out a fire, it is important to understand what caused the fire in the first place. Putting water on a grease fire will not only not help—it can make it worse. Similarly, trying to use typical interventions for depression for dysphoria not only will not help, but may also invalidate the patient and make them feel worse about not being seen or heard.

“Max” is an affirmed male (assigned female at birth), aged 14 years, who presented to our program to discuss gender-affirming care. Max reported that he had always known he was a boy and had preferred stereotypical masculine clothing, mannerisms, and activities for as long as he could remember. Max was raised by his maternal aunt “Linda,” who was his sole custodian. Both of Max’s parents had struggled with substances since he was a young child, and they did not have secure housing. None of Max’s family consistently used his chosen name or pronouns, although teachers and peers regularly used them in school. Linda was convinced that Max’s identity was “just a phase” and that the real presenting problem was that he had an eating disorder and was depressed. Linda wanted Max to be admitted to an inpatient unit, as she believed he needed “to get more meds.” She was very upset that the school was “reinforcing ‘her’ issues.”

Upon further discussion alone with the patient, he reported he was restricting food intake because he wanted to stop his menses, as it was very distressing, and he wanted to prevent his chest from growing, as he did not have access to a binder to compress his chest area. He experienced a lot of gender dysphoria when thinking about or discussing his body/bodily functions. Max also reported that he felt like his family would never understand him, use his name or pronouns, or allow him to proceed with any medications to stop his menses, let alone masculinize his body. To “let out” some of his pain, Max would use pencil sharpeners to cut his arms and thighs. Although he felt supported by friends and teachers at school, he felt his family would never accept him, would always make fun of him, and would never support who he is.

In this case example, we see issues such cooccurring gender dysphoria (eg, discomfort with body, effects of estrogen-based pubertal development), symptoms of depression, and restrictive eating. Max’s discomfort with his body and attempts to align his body with his gender identity appear to be directly impacting his eating. Therefore, traditional treatment for an 

 would not work with Max, and it could potentially lead to more gender dysphoria, depressive symptoms, and self-injurious behavior.

Relatedly, Max’s nonaffirmation at home, negative expectations about his future ability to identify as male in the eyes of his family, and negative expectations about treatment appear to be directly related to some of his depressive symptoms and self-injurious behaviors. In addition to a traditional 

, dialectical therapy, or assertive community therapy approach, understanding the GMSRM and educating the family members on the importance of using chosen name/pronouns to decrease depression and suicidal ideation would be imperative to share, as would the general importance of family and peer support.

To conceptualize the presenting problem as well as understand any maintaining factors, clinicians should consider exploring the following issues:

 What has their journey exploring their gender identity looked like? Who has been supportive of this exploration? How has society impacted their views on gender?

 What are their experiences of discrimination, rejection, victimization, and/or nonaffirmation in school? At home? With peers? With immediate as well as extended family members?

 Who is supportive of the youth, their gender journey, and the way they choose to express themselves? Are there differences by domain (eg, family, peers, school, online)?

 Is the youth experiencing negative mood, anger, or thoughts of suicide? How are these feelings related to their gender identity, internalized transphobia, or the felt need to conceal who they are for fear of repercussions or other fears of victimization/nonaffirmation?

 Have they experienced any traumatic events related to their gender identity or expression that may be impacting their sleep, eating, or ability or concentrate?

 Have they been controlling their eating to change their body shape or functions to be more congruent with their gender identity (eg, restricting food to stop menses or decrease curves or eating more to increase curves)?

 How does the youth experience gender joy? How does this impact mood? Can the youth experience gender joy in a safe manner?

TGD youth experience numerous environmental stressors (eg, victimization, invalidation, rejection) as well as gender dysphoria that can contribute and add to preexisting conditions (eg, depression, suicidality, self-injurious behavior, etc).

As clinicians, it is our duty to assess these various contributing factors and ensure the best treatment options for our patients by utilizing the most up-to-date data and protocols. We also have the unique opportunity to potentially be the first person who says to a trans young person, “I see you,” “You are valid,” and most importantly, “There is a future in which you can exist as the person you know you are.”

The advocacy work necessary in providing support for TGD youth allows us to show our patients that they matter and deserve rights. It also shows them that they are not alone on their gender journey.

is associate professor of psychiatry at Yale School of Medicine, and director and cofounder of the Yale Pediatric Gender Program. She is also a Public Voices fellow of the OpEd Project.

is a predoctoral fellow at Yale School of Medicine.

Supporting youth mental health during the COVID-19 pandemic.

2. National survey on LGBTQ youth mental health. The Trevor Project. 2021. Accessed January 3, 2022. 

https://www.thetrevorproject.org/survey-2021/

Substance abuse prevention, assessment, and treatment for lesbian, gay, bisexual, and transgender youth.

Exploring cross-sectional predictors of suicide ideation, attempt, and risk in a large online sample of transgender and gender nonconforming youth and young adults.

6. Marshall E, Claes L, Bouman WP, et al. 

Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature.

7. Johns MM, Lowry R, Andrzejewski J, et al. 

Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students – 19 states and large urban school districts, 2017.

Transgender population size in the United States: a meta-regression of population-based probability samples.

9. Thoma BC, Salk RH, Choukas-Bradley S, et al. 

Suicidality disparities between transgender and cisgender adolescents.

Suicide attempts among a cohort of transgender and gender diverse people.

11. Hendricks ML, Testa RJ. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the Minority Stress Model. 

Professional Psychology: Research and Practice. 

Transgender and gender-diverse youth experience higher rates of depression, suicidal behaviors, and self-injury than their cisgender peers. Here's what you need to know.  

Gender Issues

Our Women Deserve Better

Gender and Sex Issues in Bipolar Disorder

Insomnia and Cognition in Males vs Females With Schizophrenia

From the Pages of Psychiatric Times: April 2022

Disentangling the Web: Comorbidity Issues in Gender-Diverse Youth

Why Men and Women May Respond Differently to Psychological Trauma

Evaluating Every Patient

Violence Against Women and Acquired Brain Injuries

Biopsychosocial Explanations for Gender Disparities in Autism

The Relationship Between MDD and Lower Vitamin D Levels in Women