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The following poster presentations at the American Pharmacists Association (APhA) Annual Meeting & Exposition highlighted a number of changes facing psychiatry today.

Concurrent Benzodiazepine, Opioid Use Risks

Because more than 30% of overdoses involve a combination of benzodiazepines and 

, and more than 115 Americans die from opioid overdose every day, the investigators conducted this study to assess how much patients know about the increased risk of adverse events, overdose, and death associated with taking 

 and opioids concurrently. They also focused on the role of education, surveying study participants both before and after educational intervention. The study included 9 participants (33% male; 66% female; median age 59 years) who had been prescribed a benzodiazepine (Xanax [alprazolam], 77%; Klonopin [clonazepam], 22%; or Ativan [lorazepam], 11%) and an opioid (Norco [hydrocodone/acetaminophen], 55%; Percocet [oxycodone/acetaminophen], 22%; Roxicodone [oxycodone], 11%; or Roxanol [morphine sulfate], 11%). Participants were surveyed both before and after receiving information detailing the increased risks associated with concurrent benzodiazepine and opioid use. Each survey asked them to rank their knowledge of the medications, the potential adverse effects and 

 risk of the medications, and the risks of alcohol consumption on a scale from “unaware” to “minimal” to “good” to “excellent.”

In the presurvey, each knowledge category was divided among “excellent,” “good,” and “unaware” rankings, with “minimal” only appearing in the knowledge of overdose category at a little over 20%. Most participants ranked their knowledge as “excellent” in only the knowledge of medications category (a little more than 40%), with “good” leading the rankings in the potential adverse effects and alcohol consumption categories nearly 60% and a little more than 40%, respectively. Around 20% of participants ranked their knowledge as “unaware” across all 4 knowledge categories. In the postsurvey, no participants ranked their knowledge as “unaware” or “minimal” in any category. In both the knowledge of medications and the potential adverse effects categories, patients ranked their knowledge as “good” or “excellent” at around 80% and around 20%, respectively. In knowledge of 

, the majority of participants (around 90%) ranked their knowledge as “excellent,” with the remaining 10% ranking it as “good,” and 100% of participants ranked their knowledge of overdose—the category with the most varied results in the presurvey—as “excellent.”

Although patient education resulted in clear improvement of self-reported knowledge and understanding, only 1 participant changed their medication regimen to lower the risks of adverse events. According to the investigators, this means that patients are reluctant to change their prescribed medications even with greater awareness of the risks.

“Overall, patients can have a good baseline knowledge, but the results of this study demonstrate how pharmacists can further improve patient understanding… and knowledge of the medications [patients] are currently prescribed,” the investigators concluded.

In their poster presentation, Kafi Friday, BA, PharmD candidate 2023; and Prashant Sakharkar, PharmD, MPH, explained that sexual minorities, or individuals with nonheterosexual sexual orientation, face increasing challenges in achieving health equity, due to stigma and discrimination.

 Via a retrospective cohort study, the investigators sought to examine health disparities and level of depression among 

; compare the prevalence of sexually transmitted infections, 

, illicit drug use, and alcohol use in use in sexual minorities; and determine predictors of depression among sexual minorities.

The study’s results painted a grim picture for sexual minorities: sexual minorities were 3 times more likely to have gonorrhea and chlamydia infection, 65% more likely to use illicit drugs, 52% more likely to be a smoker, 3 times more likely to experience 

, and 2 times more likely to see a mental health clinician.

These findings suggest that depression can be a consequence of health and behavioral disparities. Screening—particularly in females who identify as a sexual minority, smoke, use illicit drugs, are under the age of 45, and are poor—might help in early intervention. Furthermore, the investigators noted future research should examine the association of depression, 

Want to learn more on the advances in psychiatry? Join us this August at the 2022 Annual 

™ World CME Conference. For more information and to register, visit 

1. Baciu A, Negussie Y, Geller A,alWeinstein JN, eds. 

Communities in Action: Pathways to Health Equity.

Catch up on all the latest from the American Pharmacists Association (APhA) Annual Meeting & Exposition.

APhA Conference Addresses Depression, Benzos

Teralyn Sell, PhD, MS, NCC, LPC, shares tips on how to improve patient libido, which can greatly impact mental health. 

holds a doctorate in psychology and is the founder of Pro Recovery Rx, a supplement line dedicated to supporting brain health for individuals in addiction recovery. She also teaches a class called NeuroHealth Coach, which helps professionals integrate brain health into their daily lives.

What 3 emotional stressors may be impacting your patient's sex drive? 

3 Emotional Stressors That Impact Libido

Kafi Friday, BA, PharmD candidate 2023; and Prashant Sakharkar, PharmD, MPH, shared their poster “Examining Health Disparities and Level of Depression among Sexual Minorities: A Population based Cross-sectional Study” at the American Pharmacists Association 2022 Annual Meeting and Exposition.

Friday and Sakharkar argued that sexual minorities, or individuals with nonheterosexual sexual orientation, face increasing challenges in achieving health equity, due to stigma and discrimination.

 In a retrospective cohort study, the investigators sought to examine health disparities and level of depression among sexual minorities; compare the prevalence of sexually transmitted infections, smoking, illicit drug use, and alcohol use in use in sexual minorities; and determine predictors of depression among sexual minorities.

The study’s results painted a grim picture for sexual minorities: sexual minorities were 3 times more likely to have gonorrhea and chlamydia infection, 65% more likely to use illicit drugs, 52% more likely to be a smoker, 3 times more likely to experience severe depression, and 2 times more likely to see a mental health clinician.

These findings suggest that depression can be a consequence of health and behavioral disparities. Screening—particularly in females who identify as a sexual minority, smoke, use illicit drugs, are under the age of 45, and are poor—might help in early intervention. Furthermore, future research should examine the association of depression, gender, and sexual minority status.

1. National Academies of Sciences, Engineering, and Medicine; Health and

Medicine Division; Board on Population Health and Public Health Practice;

Committee on Community Based Solutions to Promote Health Equity in the

United States; Baciu A, Negussie Y, Geller A, et al. 

According to this study examining sexual minority patients, depression can be a consequence of health and behavioral disparities. 

A Consequence of Health Disparities: Depression Among Sexual Minorities

In 1970, a group of gay and lesbian activists made history when they disrupted the annual meeting of the American Psychiatric Association (APA) in San Francisco. Outside the convention center, they formed a human chain to prevent visiting psychiatrists from entering. Inside, they interrupted sessions on transsexualism, laughed at a purported expert on homosexuality, and were so disruptive that a panel titled “Issues of Sexuality” it had to be adjourned.

A year later, they returned with the same demand: delist homosexuality from APA’s Diagnostic and Statistical Manual—where it had been classified as a sexual deviation.

In 1972, the APA allowed a panel of gay activists to make their case. Among them was John E. Fryer, MD, a psychiatrist who appeared in disguise, worried he might lose his license because he was gay.

In 1973, the APA put the issue to a vote, with the majority of attending psychiatrists agreeing to remove homosexuality as a mental disorder from DSM-III. However, the APA compromised by replacing the term 

. This, they argued, would allow homosexuality to be considered an illness if an individual distressed with being gay sought psychiatric help to reverse it.

The APA took the final step in 1987 and dropped this reference completely. They officially adopted what is considered a normal variant view on sexual identity. Individuals could, they acknowledged, be born gay.

It is against this backdrop that the uneasy relationship between psychiatry and the 

lesbian, gay, bisexual, transgender, queer, and intersex community

 (LGBTQI) continues to evolve. While there are far more protections than there were in the 1950s, this is a group that still struggles to find acceptance, especially its 

The ideal model of health care is that patients receive unbiased care regardless of gender identity or sexuality. In reality, however, clinicians may both consciously and subconsciously discriminate against members of the LGBTQI community, causing many to forego needed care.

 associated with minority stress, or the unique experiences associated with homophobic victimization.

 Many grapple with feelings of shame, rejection, and depression. They are the target of abuse, trauma, and bullying. As a result, they experience higher rates of homelessness, substance abuse, and suicide.

As mental health professionals, it is our ethical responsibility to identify our biases as clinicians. We need to educate ourselves about the needs of this unique and ever-evolving population, to provide the best care possible, and to do so in a way that does not perpetuate the stigma and trauma many sexual minorities contend with daily.

Health Disparities in the LGBTQI Community

As of 2017, there were 9 million adults in the United States, about 3.8% of the country’s population, who 

identified as lesbian, gay, bisexual, or transgender

It takes incredible courage to come out in front of family, friends, school, work, and society at large. It can be an extremely vulnerable experience that can elicit reactions of anger, rejection, and even violence from others. Additionally, there are many subpopulations within the LGBTQI community that have their own unique risk factors that must be considered in the context of care.

, 39% said they had been rejected by a family member or friend because of their sexual orientation. About 30% said they had been attacked or threatened because of it, and 58% said they were the target of jokes or slurs.

LGBTQI individuals are more than twice as likely to experience a mental disorder compared to heterosexual men and women. They are also 2.5 times more likely to experience depression, anxiety, and substance misuse.

Almost 12% of gays, lesbians, and bisexuals have considered attempting suicide, compared to 2.3% of heterosexual individuals. With transgender individuals, this number jumps significantly to 30.8%.

Another big challenge facing the LGBTQI community is substance abuse and homelessness. 

 on drug use and health revealed that 39.1% of sexual minorities used illicit drugs, compared to 17.1% among sexual majorities.

 than non-LGBTQI youth. And black LGBTQI youth were even more at risk for homelessness. While 7% of black non-LGBTQI youth were homeless in the United States, that number jumped to 16% for black LGBTQI youth.

These statistics for youth are particularly troubling. More youth are coming out as gay or transgender at younger ages, perhaps due to the growing social acceptance for LGBTQI communities. The average age of coming out was around 14 years old, according to data collected between 2000 and 2010. A decade earlier, this age was 16. In the 1970s, it was 20. Despite this trend, concerns about the rising prevalence of adolescent LGBTQI mental health issues are increasing.

Perhaps because they are already grappling with identity development, adolescents are already at increased risk for suicide; it is a 

 LGBTQI youth, however, tend to have higher rates of mental health issues, with 18% meeting the criteria for depression, 11.3% experiencing posttraumatic stress disorder, and 31% reporting suicidal behavior at some point during their lives. This compared to national youth rates of 8.2%, 3.9%, and 4.1%, respectively.

The reason behind these rates may have to do with increased peer pressure experienced during these ages. One 2012 study pointed to stronger prejudicial attitudes and homophobic behaviors among youth 12 to 18 years old, especially among boys.

 revealed that 86% of LGBTQI students experienced harassment or assault at school, according to the Gay, Lesbian, & Straight Education Network (GLSEN), a national organization that supports the LGBTQI community in K-12 schools.

When LGBTQI people turn to mental health providers for help, they are often let down. Almost one-sixth of LGBTQI adults have felt discriminated against at a doctor’s office, while one-fifth say they avoid medical care altogether due to their fear of discrimination, 

 conducted by Harvard University, National Public Radio, and the Robert Wood Johnson Foundation.

A 2018 Harvard panel said health care providers were woefully unprepared to address the needs of the LGBTQI community. Panelists said providers needed to do a better job gathering data about these patients, even if it meant asking them direct questions about their sexual health.

 For many providers, improvements in mental health care must be based on increased education and understanding of how different people experience and express gender identity.

Understanding Gender Identity and Expression

Today, there are increasing efforts being made to explore what, exactly, gender is and how it should be defined. In Eurocentric models rooted in colonialism, gender has been identified as a 

that distinctly categorizes individuals as either male or female based on their sex.

 It operates on the idea that gender can be visually seen as a bodily characteristic, with males having penises and females having vaginas. Gender-identity research is shifting away from this binary approach and acknowledging that the idea of gender exists on a spectrum. It is not defined by simplistic biological characteristics and is 

While our understanding of the concept of gender is evolving, gender has been postulated to encompass 4 parts: anatomical sex, gender identity, legal gender, and gender expression. Anatomical sex generally refers to genitalia, chromosomes, and bodily attributes. Gender identity refers to one’s sense of self, which can be fluid and change over time and within context. Legal gender is tied to an individual’s assigned gender at birth and is used as a way to measure differences between genders, such as health and wage disparities. Gender expression is how a particular individual presents their gender identity to society, usually through appearance, dress, and behavior. Cisgender refers to those whose self-defined gender identity matches their assigned gender at birth. Transgender refers to others whose assigned gender at birth does not match their self-identified gender.

The problem with a simple binary description of gender identity tends to be with its limitations. In research studies, for example, most demographics include gender responses with very little reflection on why it is included or 

 This standard fails to consider findings related to other gender identities, which can provide results that are inaccurate or misrepresented. Additionally, by only giving male or female as gender options, it immediately discriminates against anyone who does not identify as either.

This discrimination continues in other areas. Even though APA’s recognition of gender dysphoria as a diagnosis is not necessarily stigmatizing, it is the gatekeeping of care that perpetuates the stigma. In addition to a gender dysphoria diagnosis, transgender individuals, for example, need to jump through significant hoops to access gender-affirming care—including psychological evaluations, letters of support, and therapy.

These are just some examples of how the mental health community needs to shift awareness to treat a population desperately in need of treatment and acceptance.

For decades, psychiatry viewed being gay as a degenerative disorder. It created a deep scar that the mental health industry must now work to mend by setting aside biases, broadening our understanding, and earning the trust of LGBTQI patients. To do so, it is vitally important to refrain from making assumptions about a patient’s gender, sexuality, or sexual identity. It is always necessary to ask about an individual’s pronouns. Do not refer to them as preferred pronouns; they are simply pronouns.

Clinicians are obligated to be aware of their own biases, both conscious and subconscious, that can potentially negatively influence the care provided to their clients. This will help avoid any countertransference of opinion from provider to client.

Creating a therapeutic container is essential for holding patients in a safe place that allows them to express any feelings of pain and shame.

 This is based on Carl Jung’s concept that compares the therapeutic container to an alchemical container that safely holds the feelings and thoughts of patient and analyst alike.

 authors Caroline Shahbaz, BBSc(Hons), MPsych, MA; and Peter Chirinos, MA, LPC, NCC, DCC; offer the following guidelines to create a therapeutic container:

- Validate the sociopolitical issues confronting a patient’s marginalized community

- Do not assume their psychological problems are a function of their sexuality

- Connect patients with appropriate communities and networks

LGBTQI patients may engage in sexual activities that a provider may find disturbing and uncomfortable, which is indicative of a clinician’s own conscious and unconscious biases that can impede a patient’s progress in care. As with any patient population, when treating sexual minorities, competent care as it relates to this population must be the standard of practice and directly translates into making patients feel accepted and validated.

By providing competent care as clinicians, we can continue to bridge the gap of trust and open new appropriately informed ways to treat and support the LGBTQI community. In a sign of hope for the future, the American Psychoanalytic Association issued what it called an “

” in 2019 to members of the LGBTQI community for its “role in the discrimination and trauma caused by our profession.”

 Moving past apologies, the mental health community needs to focus on restorative justice on both the macro and micro levels. This can include educating themselves and their peers, centering learning from LGBTQI individuals, using cultural safety and trauma-informed frameworks for care, and reducing gatekeeping to gender-affirming care.

Additionally, it is vitally important to advocate for policy changes both in the mental health field and with broader causes that disproportionately impact LGBTQI individuals, such as fair housing, harm reduction, and antidiscrimination legislation. Only a multi-pronged approach will ensure members of the LGBTQI community receive the mental health services many of them so desperately need.

is an Adolescent and Adult Psychiatric Mental Health Nurse Practitioner with 

1. Poteat VP, Scheer JR, Mereish EH. Factors affecting academic achievement among sexual minority and gender-variant youth. 

2. National Alliance on Mental Illness. LGBTQI. Accessed June 3, 2021. 

https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI

3. A Survey of LGBT Americans. Pew Research Center. June 13, 2013. 

https://www.pewresearch.org/social-trends/2013/06/13/a-survey-of-lgbt-americans

4. Medley G, Lipari RN, Bose J, et al. Sexual orientation and estimates of adult substance use and mental health: results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. October 2016. 

https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm

5. Chapin Hall at the University of Chicago, Voices of Youth Count. Missed opportunities: LGBTQ youth homelessness in America. April 2018. 

https://voicesofyouthcount.org/wp-content/uploads/2018/05/VoYC-LGBTQ-Brief-Chapin-Hall-2018.pdf

6. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. 

7. Centers for Disease Control and Prevention. Adolescent health. Updated April 14, 2021. Accessed June 3, 2021. 

https://www.cdc.gov/nchs/fastats/adolescent-health.htm

8. Poteat VP, Anderson CJ. Developmental changes in sexual prejudice from early to late adolescence: the effects of gender, race, and ideology on different patterns of change. 

9. GLSEN. The 2019 National School Climate Survey. 2019. Accessed June 3, 2021. 

https://www.glsen.org/sites/default/files/2020-10/NSCS-2019-Executive-Summary-English_1.pdf

10. Powell A. The problems with LGBTQ health care. 

https://news.harvard.edu/gazette/story/2018/03/health-care-providers-need-better-understanding-of-lgbtq-patients-harvard-forum-says/

11. Lugones M. The Coloniality of gender. 

https://globalstudies.trinity.duke.edu/sites/globalstudies.trinity.duke.edu/files/file-attachments/v2d2_Lugones.pdf

12. Ainsworth C. Sex redefined: the idea of 2 sexes is overly simplistic. 

https://www.scientificamerican.com/article/sex-redefined-the-idea-of-2-sexes-is-overly-simplistic1/

13. Lindqvist A, Sendén MG, Renström EA. What is gender, anyway: a review of the options for operationalising gender.

https://www.tandfonline.com/doi/full/10.1080/19419899.2020.1729844?scroll=top&needAccess=true

14. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. 

15. Finlay L. Holding, containing and boundarying. In: 

Relational Integrative Psychotherapy: Engaging Process and Theory in Practice

The uneasy relationship between psychiatry and the LGBTQI continues to evolve. How can it be influenced for the better? 

Bridging the LGBTQI Gap in Care: Why Psychiatrists Need To Do More To Treat These At-Risk Communities

What Is an SGM Community?

What terms are used to describe SGM and LGBTQ+ identities? 

SPECIAL REPORT: SEXUAL AND GENDER MINORITIES

“Jessica,” a 13-year-old transgender girl, lives in a rural community where no other individuals identify as transgender. She has a supportive family and was able to safely come out to her parents. She socially transitioned 2 years ago. Despite support at home, Jessica and her family have faced challenges at school. The other teens in her grade did not accept her when she came out. They started to call her names such as “she-male” or “it.” She started feeling depressed and avoiding school. Her parents intervened and spoke with a counselor at school. The counselor remembered a training by the State Department of Education where they discussed a comprehensive bill supporting transgender youth. The school was required to educate staff and eliminate any discrimination. The teachers were given resources to help them better understand Jessica’s journey, and those resources helped them support her better. The bullying decreased and Jessica’s depression, anxiety, and school attendance improved.

“John,” a 16-year-old transgender boy, lives in a large city and recently started high school. He received a diagnosis of depression and has had 2 hospital admissions for suicide attempts beginning at age 12. He has explored his gender over the past 3 years and came out to his parents a year ago after discussing it with his therapist and psychiatrist, both of whom have been supportive. The treating team was able to help his parents learn about John’s gender development, and his parents also became supportive.

Unfortunately, John’s school has been a major stressor for him. He was bullied for being a tomboy at school and is scared to come out. He wants to start testosterone treatment but fears a negative reaction from his peers. His parents have spoken to the school, asking administrators to help with his transition and provide a safe environment to come out.

One of the parents of another student who was involved in bullying John raised issues with his transitioning and referred to the recent bill that their state passed, which bans transgender children from using their bathroom of choice. John has been holding his urine at school until he gets home. His depression escalated, and his grades dropped. His family is struggling to find a safe environment for him.

Gender-diverse individuals have been marginalized and discriminated against in many communities throughout history. Modern psychiatry initially adopted a pathological view of transgender identity as well. However, the work of human rights advocates, supported by growing medical evidence, has caused medical and health care organizations to reverse their discriminatory stances against transgender individuals over the past few decades.

transgender identities or nonconforming gender presentations

 are not pathological nor indicate a disorder. These individuals may require medical interventions to stop the course of endogenous pubertal changes in order to match their desired gender identity, as outlined in guidelines from the World Professional Association for Transgender Health Standards of Care and Endocrine Society.

It is well established that discrimination negatively impacts transgender and 

. The rate of depression and anxiety among transgender and gender-nonconforming youth is several times higher than the rate of their cisgender peers.

 These youths are more likely to seriously consider suicide or illegally use substances. These effects are mainly due to structural discrimination, both in society’s attitudes and the legislative system.

 Coercive interventions that even try to alter gender identity, sometimes called “conversion therapy,” are harmful and ineffective.

Lack of school belonging as well as interpersonal microaggressions have been shown to be directly linked to 

 Conversely, simple acts of affirmation have demonstrated profound positive effects. Even the repeated use of a transgender or gender-nonconforming youth’s chosen name can reduce suicidal thoughts and behavior.

 The more widely it is used, the stronger the effect.

The positive effects of gender-affirming care on transgender or gender diverse youth are similarly well-documented. Gender-affirming care improves positive mental health outcomes, and youth who receive it are less likely to attempt suicide.

 Pubertal suppression decreases depressive symptoms, as well as behavioral and emotional problems.

 Likewise, gender-affirming hormone therapy also decreases behavioral and emotional issues and improves body image and psychological well-being.

Recently, Jessica began puberty. She is not certain whether she wants to take gender-affirming hormones. Her family physician recommended that Jessica and her family speak with an endocrinologist. Jessica’s town does not have an endocrinologist. In fact, the nearest endocrinologist is Dr Sanchez, whose practice is about an hour away.

Dr Sanchez keeps up with the latest literature and knows about the beneficial effects of gender-affirming care. He mentioned the possibility of taking leuprolide to temporarily suppress puberty while Jessica decides what she would like to do in the future. He consulted with a colleague who is more experienced in this area to ensure the correct dosing. He also helped Jessica decide to preserve fertility by freezing her sperm. Jessica’s family enlisted a psychiatrist to ensure good psychological support. The psychiatrist coordinated with Jessica’s school counselor for wraparound care.

John’s parents decided to pull him out of his district high school. He enrolled in a day treatment program, and they are working with their psychiatrist to find an alternative school environment where John can continue his education without discrimination. Most schools are pressured by the recent legislation and fear an antitransgender parent at school can sue them. For now, the parents decided to home-school John and focus on his recovery from depression. They consulted with a pediatric endocrinologist to discuss hormonal treatment options. Dr Smith has treated a few other transgender youths.

The state where John lives recently proposed a law to block gender-affirming care in transgender youth. Under this law, the psychologist and psychiatrist who both directly participated in John’s care would be fined, and Dr Smith would be fined and jailed for prescribing hormonal treatment. Without his treatment team, John feels hopeless. If this bill is passed, John will not be able to start testosterone treatment until he is 18 years old.

Despondent, John contemplated suicide. The focus of his care shifted toward keeping him alive. His mental health team reached out to their local professional organizations to mobilize other colleagues against this discriminatory bill.

The rights of transgender youth have become a battleground for political agendas at the intersection of structural discrimination and gender-affirming care. Dozens of states have proposed bills that would criminalize gender-affirming care (Figure). Doctors who perform this care would be subject to fines, imprisonment, or even loss of licensure. Laws criminalizing gender-affirming care are a major legislative theme this session, but dozens of other antitransgender bills join them. Currently there are more than 45 such 

 in local governments across the United States, following failed proposal bills in several states last year and similar so-called “bathroom bills” over previous years.

 A majority of these bills seek to deny transgender youth their affirmed gender, forcing them to use restrooms or play on sports teams according to their sex assigned at birth (so-called sport and bathroom bills). Only 8 of the proposed antitransgender bills this session were discriminatory in a way other than these 2 categories.

The stories of Jessica and John are the same stories of hundreds of thousands of youth in the United States. Child psychiatrists and other mental health professionals are treating many of these youth. Their presentation can be complex, and treatment requires an in-depth understanding of their gender development, family dynamics, and psychosocial environment. Care can also be further complicated by state legislation. Physicians and other health care professionals are bound ethically not to harm their patients and provide medically necessary services to help them. Discriminatory bills, such as those proposed where John lives, can create a conflict for health care professionals between ethically appropriate care and legally acceptable guidelines. Although some think that delaying affirmative care until the age of majority is a harmless option, there is solid and growing evidence that affirmative care improves a transgender youth’s mental health.

Establishing good mental health for a transgender youth often starts from a nucleus of support, whether that is in the home, the school, or a close group of friends. This support can buffer these youth from the negative impacts of antitransgender legislation. As in the care of many other youths, identifying ways to increase available support or add additional support provides significant benefit to overall psychological well-being. Psychiatrists can be a part of that nucleus of support for these youth.

In a more active role, doctors can be crucial in advocating for the well-being of transgender youth. Major medical and health care associations have local organizations in each state. Educating members of these organizations and mobilizing them to advocate against discriminatory bills can be an important tool to help youth like John, whose life can change significantly with a single law. As such, it is vital that advocates call their state representatives when antitransgender legislation is introduced. If mental health experts do not educate legislators on the mental health impacts of these bills, no one else will. Psychiatrists have a duty to patients that goes beyond the boundaries of the office; in some instances, the ethical dilemmas may help psychiatrists recognize the need to raise their voices and stand up for their patients (

There is much that psychiatrists and other mental health professionals can do to support transgender youth patients: donate time or money to organizations that support transgender youth; speak and advocate for transgender youth by working with state professional organizations; call state legislature representatives when antitransgender legislation arises, highlighting the adverse mental health impacts such legislation would cause; and help establish more support at the family and school level.

is a psychiatrist in the United States Department of Veterans Affairs’ newly created lesbian, gay, bisexual, transgender, queer specialty service in Colorado. 

is a clinical assistant professor of psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

1. Davies RD, Davies ME. The (slow) depathologizing of gender incongruence. 

2. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. 

3. Becerra-Culqui TA, Liu Y, Nash R, et al. Mental health of transgender and gender nonconforming youth compared with their peers. 

4. Chavez, AM, Janssen A. Structural stigma. 

5. Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults. 

6. Austin A, Craig SL, D’Souza S, McInroy LB. Suicidality among transgender youth: elucidating the role of interpersonal risk factors. 

7. Russell ST, Pollitt AM, Li G, Grossman AH. Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth. 

8. Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal suppression for transgender youth and risk of suicidal ideation. 

9. de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. 

10. de Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. 

11. Legislative tracker: anti-transgender legislation. Freedom for All Americans. Accessed March 23, 2021. 

https://freedomforallamericans.org/legislative-tracker/anti-transgender-legislation

Due to discrimination's negative impact, transgender and gender-nonconforming youth are several times more likely than the rate of their cisgender peers to have depression and anxiety.

The Negative Impact of Current Legislation on Gender Diverse Adolescents

Despite rapid social progress, including the landmark United States Supreme Court ruling on same-sex marriage in 2015, challenges remain for young individuals who are 

lesbian, gay, bisexual, transgender/trans, or queer

 (also known as sexual and gender minority or SGM youth). Fortunately, since the start of this century, online environments have revolutionized the lives of young SGM individuals, so even those in the most remote of locations can access discrete and timely supports. While the internet has generated many benefits for SGM communities, it has also created new problems, such as the rise of internet-based homo-, bi- and trans-phobic bullying, online sexual exploitation, as well as worrying conversion tactics.

Given the diversity implicit under the wider SGM umbrella, it is important to briefly define these unique subpopulations and their mental health needs before delving into the impacts of online environments for these young people.

To identify as lesbian, gay, or bisexual (LGB) is to claim a certain, often politicized, sexual identity label. However, sexual attractions and sexual behaviors are other important dimensions of human sexuality.

 Depending on the dimension of sexuality assessed, estimates of nonheterosexual prevalence varies considerably, even when estimates are derived from population-based studies.

Assuming questions related to sexuality are included in these large-scale studies, researchers have consistently reported that a substantial proportion of youth identify as being a sexual minority individual. For instance, up to 8% of youth identify as bisexual, and up to 3% of youth identify as lesbian or gay.

 Meanwhile, although being LGB is related to sexuality, being transgender/trans pertains to one’s 

. (See What Constitutes a SGM Community for more information.)

Robust population-based data have demonstrated SGM youth are at an elevated risk of a range of mental health problems, including 

, depression, anxiety, and addiction issues.

 Unfortunately, there is limited population-based data focused on the mental health of transgender adolescents.

For instance, a systematic literature review and meta-analysis of 

 attempts among SGM young individuals identified only a single study in which the results for transgender adolescents were presented separately, and not combined together with SGM youth.

 Based on the meta- analysis, transgender adolescents were nearly 6 times more likely to attempt suicide when compared to their cisgender peers.

The increased rates of mental health problems are hypothesized to be caused by minority stress, whereby the mistreatment associated with the high levels of stress these youth encounter is thought to place them at an increased risk for emotional problems.

 Experiencing this mistreatment also results in internalizing the negativity associated with anti-SGM messages, which can lead to mental health issues.

Opportunities for Affirmation and Community

The internet has initiated a revolution for SGM youth because geographic boundaries are no longer limiting; these young people can now connect online with others like themselves. As such, the internet has exerted a powerful influence, with numerous advantages. For instance, those in rural or more socially hostile environments can obtain support via online groups as well as from charitable organizations that provide free online services 24 hours a day, 7 days a week (

). This is a huge advantage. SGM-specific information on 

SGM youth in high-income countries are thought to be coming out at younger ages.

 Consequently, many will still be living at home and will be dependent on their families when they first come out. Unfortunately, not all families will be supportive, and some will actively attempt to secure services and information—either online or face-to-face—aimed at “converting” or “correcting” the SGM youth. This practice still occurs, despite the disapproval of professional bodies toward reparative or conversion therapy, including 

 from the American Psychiatric Association

American Academy of Child and Adolescent Psychiatry

Bullying, Harassment, and Exploitation Risks

Bullying behaviors and trolling via social media platforms are concerning issues in general and especially for SGM youth. It is worth noting that some of this mistreatment can take the form of horizontal violence in which one SGM youth bullies another SGM youth. Both young individuals as well as health professionals have previously identified internet safety and security issues being important considerations.

Online environments have revolutionized the lives of young SGM individuals, but also created unforeseen issues...

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