Experts in transgender health from around the world are participating in and making more sweeping efforts to streamline mental health care for all sectors of the population.
Last month, I was contacted by a psychiatrist seeking to consult my expertise in transgender care for a clinical dilemma. A patient of hers needed a second letter for surgery from a psychiatrist in order for the surgery to be covered by insurance. The patient’s therapist had already written a letter supporting surgery. The psychiatrist was aware that the World Professional Association for Transgender Health Standards of Care 7 (WPATH SOC 7) criteria for surgery was that mental illness was “well-controlled.”1 The patient had missed appointments with the psychiatrist for treatment of a mood disorder with substance use. However, the psychiatrist felt the patient would benefit from surgery. Could she write the letter?
As a co-author of WPATH SOC 7, I had heard variations on this question many times. And as chapter lead of the mental health chapter in the upcoming WPATH SOC 8, I have been working to try to provide more clear guidance to psychiatrists and other mental health professionals on the care of transgender people who also have mental illness and substance use disorders.
Since 1979, WPATH has periodically revised its Standards of Care, which choreograph the multidisciplinary care of transgender (or trans) people who are transitioning.2 Mental health professionals or primary care providers can assess patients for starting hormones. One or 2 evaluations from mental health professionals are recommended before surgery. Criteria for surgery include capacity for informed consent, persistent gender dysphoria, and that mental illness, if present, is “well-controlled.” There is a recommendation that patients live in the gender role in which they intend to live, and be on a stable hormone regimen, if indicated, for a year before genital reconstruction surgery.1
From 1981 to 2014, the US Department of Health and Human Services banned reimbursement under Medicare for trans care. Coverage was excluded under Medicaid programs and most private insurance as well. The lack of insurance coverage meant that many trans people lacked access to care, and little trans care was provided by most health systems. Research was not funded in the United States.3 Physicians did not receive much training in trans care in medical schools, because academic health centers provided little care. All of this has changed dramatically in the last decade, and with increasing patient visits, training health providers in care for trans people has new urgency.3 Many states now require state-regulated private insurance and Medicaid coverage for transgender care, including surgery. Medicare has removed its ban on trans care coverage, though approval of surgical procedures are on a case-by-case basis. The Obama administration attempted to remove trans health exclusions in all states under Rule 1557 of the Affordable Care Act, though these efforts have been hampered by the current administration and a federal judge’s ruling. Removal of remaining trans health insurance exclusions awaits future court decisions or perhaps the next administration. But there has been a national sea change in insurance coverage since 2013.3,4
Because of these funding restrictions, there was little research on trans-care and mental health in the United States until the past decade, but there has been data from European studies on mental health in trans people. Swedish lifetime longitudinal data showed that trans people there who had transitioned with social transition, hormones, and surgery still had increased mental health morbidity and mortality compared to the general population.5 However, the regret rate for transition in Sweden from 1960-2010 was very low.6 A recent analysis of the Swedish data on initial publication showed a decrease in mental health utilization in those who had surgery versus those who had not7; however, the paper’s statistical analysis has been challenged.8 However, it is clear, from a meta-analysis of 72 studies from 1991 to 2017, that transition reduces gender dysphoria, improves quality of life, and that regret rates for transition are low.9
The World Professional Association for Transgender Health is now working on the Standards of Care Version 8, due to be released in 2021. WPATH SOC 8 is a far larger effort than previous Standards of Care, with many experts in transgender health from around the world participating. Of note, a far larger share of the experts are health professionals who are themselves trans.
SOC 8 includes a separate chapter in which a majority of the authors are psychiatrists, working on guidelines for patients who are trans who also have mental illness and substance use disorders. This mental health chapter, for which I am chapter lead, agreed on approximately 20 statements for which we could reach consensus on principles of care for this population. Of these, the editors chose 10 statements that are considered action statements, which guide clinician actions. These statements went to a Delphi process to reach agreement from all of the experts from all of the chapters of SOC 8. The remainder of our statements, which weren’t action statements but rather statements of good practice, may still make it into the descriptive text of the chapter.
One major shift has been away from the requirement that mental illness and substance use disorders be “well-controlled” for the patient to proceed to surgery. Instead first, the mental illness, as is the case with other surgeries, must not impair the ability to give informed consent. Second, taking the mental illness or substance use disorder into account, the benefits of proceeding to surgery must outweigh the risks. A short delay to stabilize a patient psychiatrically might be worthwhile, but the risk of delay, with exacerbation of gender dysphoria, also needs to be considered. Psychosocial and practical care can support proceeding to surgery.
In the case where the psychiatrist asked me about a patient, a moderate mood disorder with substance use in many cases would not impair ability to give informed consent. If mental illness and substance use were preventing the patient from keeping appointments for needed perioperative care, a plan for support from family or friends to assist the patient in keeping appointments might allow surgery to proceed. Other agreed upon statements include keeping a patient on longstanding hormones (unless contraindicated) when admitted to inpatient psychiatry and taking steps in inpatient and residential settings to respect patients’ gender identity.
Each of the other chapters, approximately 20 in total, also have gone through a process like that described for the mental health chapter. In addition, for the medical and surgical chapters, consultants from Johns Hopkins University conducted literature reviews and rated the evidence from clinical trials of recommended interventions.
One of the new chapters in SOC 8 will be on care of people with non-binary identities. This continues a shift in SOC, which began with the 7th Version, away from binary preconceptions of identity and of transition. An increasing number of people identify as neither male nor female, but may still experience gender dysphoria, and may still need transition care.
Much progress has been made in the past several years in caring for trans patients. With this expansion of care and recent return of care of transgender patients (including surgery) to academic medical centers, there is the promise of more research and knowledge into providing better care. Psychiatrists play an important role, especially in the care of trans people with mental illness and SUDs. WPATH SOC 8 will provide guidance in providing that care.
Dr Karasic is a clinical professor of psychiatry at UCSF, with a telepsychiatry practice in California. He can be contacted at dankarasic.com. He spoke at PsychCongress in a presentation titled “Psychiatric Care of Transgender People with Mental Illness and Substance Abuse: New Guidelines from the World Professional Association for Transgender Health Standards of Care Version 8.” The author reports no conflicts of interest concerning the subject matter of this article.
1. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th Version. Int J Transgend. 2012;13:165-232. Accessed September 9, 2020. https://www.wpath.org/publications/soc
2. Karasic DH, Fraser L. Multidisciplinary Care and the Standards of Care for Transgender and Gender Non-conforming Individuals. Schechter L & Safa, B. (Eds.) Gender Confirmation Surgery, Clinics in Plastic Surgery Special Issue. 2018;45(3):295-299. Elsevier,Philadelphia. https://doi.org/10.1016/j.cps.2018.03.016
3. Karasic DH. Protecting Transgender Rights Promotes Transgender Health. LGBT Health. 2016;3(4):245-7.
4. Byne W, Karasic DH, Coleman E, Eyler AE, et al. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. Transgender Health. 2018;3(1):57-70.
5. Dhejne C, Lichtenstein P, Boman M, et al. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE. 2011;6(2): e16885. https://doi.org/10.1371/journal.pone.0016885
6. Dhejne C et al. An analysis of all applications for sex reassignment surgery in Sweden, 1960-2010: prevalence, incidence, and regrets. Arch Sex Behav. 2014;43:1535-1545.
7. Branstrom R, Pachankis R. Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study. Am J Psychiatry. October 4, 2019. https://doi.org/10.1176/appi.ajp.2019.19010080
8. Correction to Branstrom and Pachankis. August 1, 2020. Am J Psychiatry. Accessed September 9, 2020. https://doi.org/10.1176/appi.ajp.2020.1778correction
9. What We Know. What does the scholarly research say about the effect of gender transition on transgender well-being? Cornell University Public Policy Research Portal. Accessed September 9, 2020. https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people