How can you best address and support transgender patients, as well as prevent negative outcomes?
In the United States, we have seen a “recent surge in visibility and acceptance around transgender identities,”1 even among transgender and gender nonbinary (TGNB) individuals aged 18 to 24 years old.1 Recent research by the Williams Institute at the University of California, Los Angeles, compared data from 2017 to 2020 in a report that showed while, “the percentage and number of adults who identify as transgender has remained steady over time in the United States…Youth ages 13 to 17 comprise a larger share of the transgender-identified population than we previously estimated, currently comprising about 18% of the transgender-identified population in the US, up from 10% previously.”2 Yet the experience and post-adolescent association with gender identity is heterogenous, with a variety of “transition trajectories.”3,4 Although relatively rare (~1%), some individuals may express transition regret, detransition, and even retransition distress,5 with estimates of detransitioning reaching 13.1% in one sample.6
This area has been rapidly evolving. Research has suggested that detransitioning after gender-affirming care has occurred for “various reasons,” including an evolving understanding of gender identity.7 MacKinnon et al (2022) noted that “at the individual level it is not always possible for patients—or their clinicians—to predict with absolute certainty how treatments will be experienced.” Furthermore, there have been some patients who reported that their detransition was physically and emotionally challenging; detransitioning is characterized as a period marked by increased “changes in energy and mood, worsened gender dysphoria, and overall uncertainty about detransition.” To these authors, it seems possible that, for selected individuals, these factors may act in concert to produce worsening mood symptoms, suicidal ideation, and overall suicide risk.
Some physicians providing gender-affirming medical care report their approach is now “built around preventing transition ‘regret,’” due to fears of liability. However, despite the ubiquity of “readiness” assessments in one sample of Canadian clinicians, “regret and detransitioning are unpredictable and unavoidable clinical phenomena.”3 Complicating matters further, TGNB individuals “may also go on to retransition, that is, to identify or present with yet a different gender identity. Detransition and retransition may involve a change in identity, social presentation, legal documentation, or physical interventions.”5
Given this complex and evolving phenomena, is it possible the US could witness an increase in medical malpractice litigation surrounding current practices that constitute gender-affirming care. More specifically, might there be increased malpractice claims involving negligent treatment with transitional hormones and/or surgeries for TGNB individuals?
Complicating matters further, it is difficult to determine if not providing gender-affirming treatment may lead to malpractice due to the new and relatively small research base of this rapidly growing area of health care. Consider the plausible hypothetical case of an individual who tragically dies by suicide following a denial of their gender-affirming treatment. If subsequent litigation follows, not only might the issue of causation be extremely complex, but the issue of research on rates of suicide before and after gender-affirming treatment will likely be considered. Yet at present, there is a “current lack of methodological robustness of the literature,” and TGNB individuals constitute a heterogenous group that may have differing outcomes, thereby making broad generalizations difficult.8
The Case of Ms Kiefel
Consider the case of Camille Kiefel, a 32-year-old woman who formerly identified as nonbinary.9 Ms Kiefel is suing 2 Oregon gender clinics for complications following her double mastectomy. She alleged that at the time of her evaluation for the procedure, she “was going through mental health issues including anxiety disorder, social anxiety, posttraumatic stress disorder (PTSD), major depressive disorder, and attention-deficit/hyperactivity disorder (ADHD).”9
Ms Kiefel reported she first began to perceive her gender as a distressing personal vulnerability when she was in the sixth grade. At that time, her best friend was the victim of a sexual assault. For Ms Kiefel, the assault of a friend ultimately resulted in intense “discomfort” centering around her breasts and hips. She alleged that the enduring ramifications of this experience, along with other mental health factors, were not sufficiently considered by her physicians.9 The role of trauma in Ms Kiefel’s case has echoes to the myth of Caenis. As detailed in Ovid’s Metamorphoses, following the rape of Caenis by Neptune (Poseidon in Greek mythology), Caenis voiced the desire no longer to be a woman. Therefore, Neptune transformed her into a man thereafter known as Caeneus. The case of Ms Kiefel raises the important question of trauma, and what role it might play in gender identity, or patient decisions about gender-affirming treatment.
In the area of gender-affirming medical treatment, medical processes such as informed consent, treatment capacity, and independent assessments of gender identity in order to establish the appropriate method of treatment are still developing and being debated. In many cases, an informed consent model utilized by general practitioners is more common than a mental health evaluation model. In one Australian primary care clinic, Spanos et al found that among 309 individuals seeking gender-affirming hormone treatment, 92% were assessed for the initiation of such treatment via the informed consent model. The initiation of such treatment was solely by their general practitioner. The remaining 8% of patients in this sample were referred for “secondary mental health practitioner assessment in the settings of more complex mental health conditions such as psychosis or if the GP… [felt unable adequately to] determine an individual’s ability to provide informed consent.”10
There is a growing movement to dispense with mental health “clearance” and/or independent mental health assessments prior to initiating gender-affirming treatment.11 Recent literature reflects changing attitudes toward the use of mental health assessments as a form of gatekeeping that pathologizes “transness,” which can understandably be experienced as distressing to such patients.12,13 While the history of psychiatry has previously been rooted in anglo-heteronormativity, this issue is beyond the focus of this article.14-24 In short, the DSM is a socio-culturally constructed guide that is not independent of the linguistic, cultural, philosophical, and ideological influences held by its contributors.14,25,26 While remaining attentive to these vital issues, the role of trauma and concerns regarding mental health must remain important considerations from the very first clinical encounter. Not only is this good medical practice, but it also recognizes that transgender individuals are not a homogenous group, and are likely have differing mental health backgrounds, trajectories, and exposures to trauma.
Returning to the case of Ms Kiefel, her lawsuit raises questions about how mental health, and particularly past trauma, may play a role in gender dysphoria and in the desire for some TGNB individuals to pursue treatment such as gender-affirming hormones or surgeries. Viewing traumatic experiences and gender dysphoria in strict isolation from each other may pose problems in delivering “culturally competent, evidence based, and effective treatment” given the high rate of exposure to trauma for those with gender or sexual minority status.27 Furthermore, limiting clinical focus to the stresses related to minority status and/or discrimination may risk overlooking the role of early traumatic experiences that are antecedent to a patient’s current or recent struggles.28,29 Among traumatic stressors, sexual assault has one of the highest rates of subsequent PTSD development.30 From a psychological standpoint, it seems plausible that in some instances, sexual trauma may facilitate vulnerability to gender dysphoria. Given that psychiatry is a tremendously complex field in which it is important to avoid traps of dichotomous thinking, it is prudent to carefully consider the totality of individual patient’s circumstances. Therefore, it seems inflexible to never explore whether trauma and/or PTSD related symptoms in a patient with such a history might be related to avoidance of reminders of their prior gender identity. This is particularly the case where the individual experiences their previous gender identity as distressing or unpleasant. Certainly, the unique backgrounds and variety of transgender individuals indicate that the clinical interview must adapt and take into account the diverse experiences of this heterogenous group. In turn, this may hopefully add to the research base and further improve guidelines for assessment, treatment, and documentation.
The concerns expressed here are not intended to be an explanatory model for transgender identity. The fact that a few individuals transition with the aid of gender-affirming care and later detransition, or otherwise experience regret, raises the question of how best to address and support patients, as well as prevent negative outcomes. Thus, careful physician-patient communication is needed as part of the patient consent process.
Dr Jackson is a board-certified psychiatrist in Syracuse, New York. Dr Knoll is a professor of psychiatry and director of forensic psychiatry at SUNY Upstate Medical University in Syracuse, New York. He is Emeritus Editor in Chief of Psychiatric Times and president-elect of the American Academy of Psychiatry and the Law (2022-2023). Dr McLawhorn is a board-certified psychiatrist at the University of Rochester Medical Center, and Clinical Senior Instructor (Voluntary) in the Department of Psychiatry and Crisis Services.
The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times®.
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