
- Vol 39, Issue 11
Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse
Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality.
SPECIAL REPORT: PSYCHOEDUCATION
The data is clear: We should expect an increasing number of
Case Example
For discussion purposes, consider a prototypical case of “Bar,” an 11-year-old child who presents to your office accompanied by his parents. Bar was assigned female at birth but recently began identifying with “he/him” pronouns; he is scared to face impending puberty. Bar’s father informs you that he is afraid Bar will be “bullied for being gay.”
Supporting the Patient and Their Family
Recent qualitative studies suggest that the caregivers’ response and adjustment to their TGD child’s identity development is critical to the child’s mental health.3 An integrative family therapy approach should affirm and support the TGD child in an equal partnership between the caregivers and the child.4 Addressing attunement and attachment is important for the family system, as there is likely longstanding
Distress tolerance and interpersonal relationship dynamics can be tested during a gender transition7; as a result, many with
Disclosing a shared identity with a patient can aid the therapeutic alliance by displaying understanding and empathy for the patient’s experience, which can facilitate trust and reciprocity.10,11 It is vital that providers reflect on whether self-disclosure is being done with the intent of improving patient care, and peer supervision around this can be of value.
Psychiatrists should model inclusive environments to their TGD patients within their offices and clinical spaces.12 Patients and their families should feel safe to give feedback to the psychiatrist when they fail to produce an affirming patient experience.2 In these situations, the administrative response should be transparent and timely, and it should address the root cause of the issue. Psychiatrists should collaborate and advocate with the family and other community and mental health professionals, such as school psychologists and counselors, to create affirming environments within the child’s home and school life.13 It is imperative that work with TGD patients involves ongoing feedback and participation from affected community members throughout the learning and healing process.14
To create a more affirming environment for a TGD child, psychiatrists should collaborate with the family, school, and community. For example, using noninvasive and empowering language can be a great first step in establishing not only a good environment, but also a therapeutic alliance. See
Psychiatric Terminology: Is the Field Doing Enough?
Gender Dysphoria and Its Significance in the TGD Community
Gender dysphoria is a term that originated within psychiatry. The DSM-5-TR defines gender dysphoria as “the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” Gender euphoria is an accepted term used in the TGD community that recently entered the peer-reviewed literature.15 It is defined as a “joyful feeling of rightness” and the “powerfully positive emotions” that comes from one’s gender. See
Gender dysphoria is caused by repeated exposure to gender-nonaffirming environments, which can result in higher rates of
The Gender Minority Stress and Resilience Theory
The Gender Minority Stress and Resilience Theory describes the disparate impact of risk and protective factors on the experience of internalized (proximal) and external (distal) oppression in TGD communities.34 These stress and
Minority stress models have been used to explain the increased risk for biological, psychological, and social health disparities observed in TGD communities. These biological factors include increased rates of cardiovascular disease and cancer-related outcomes, whereas psychological outcomes of minority stress include depression and suicidality.36-38 Among the TGD community, social disparities and structural disadvantages have been noted in increased rates of incarceration, housing instability, underinsurance, and risk behaviors, such as
Conclusion of Case Example
You diagnose Barr with gender dysphoria and provide supportive psychotherapy throughout the social transition process. You present Barr with information regarding his local community center, where Barr becomes active in peer support and social activities. You provide educational resources to Barr’s parents, who join their local PFLAG (Parents, Families, and Friends of Lesbians and Gays) chapter to speak with other parents of TGD children. You discuss the changes in pronouns with Barr’s school psychologist and work with school administration to help develop strategies for Barr to express his gender authentically within the school’s policies.
After a year of treatment, although Barr feels more confident in his masculine gender expression, he reports ongoing depression due to expected changes with puberty. As a result, you refer Barr and his parents to a gender-affirming endocrinologist to discuss options regarding potential puberty suppression and timing.
Concluding Thoughts
Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. This includes the use of sensitive and inclusive language and assisting the field in adapting to ongoing evolution of community standards of care. Similarly, it is important to integrate transition and resocialization efforts with the patient’s family, community centers, and school professionals.
Ms Roldán is a sixth-year medical student at Universidad Peruana Cayetano Heredia in Lima, Peru. She aspires to become a neurologist and to continue advocating through research and policymaking for the transgender community. Dr Lerario is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community.
References
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35. Heise L, Greene MH, Opper N, et al; Gender Equality, Norms, and Health Steering Committee.
36. Streed CG Jr, Beach LB, Caceres BA, et al; American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council.
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Articles in this issue
almost 3 years ago
Covering the Basics: LGBTQ+ Terminologyalmost 3 years ago
The Importance of Avoiding Implicit Bias in Advocating for Patientsalmost 3 years ago
Psychiatrist Humility and Patient Empowermentalmost 3 years ago
Advances and Challenges in Adult ADHDalmost 3 years ago
THE QUEST: Nepal Lets You Reach for the Majesty of the Summitalmost 3 years ago
Psychiatric Times™ Conference: Clinical Pearls for Treating MDDalmost 3 years ago
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