Integrating Mental Health Needs Into Transgender Healthcare

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Transgender and gender and nonconforming individuals face higher risks for experiencing mental health disorders than cisgender peers, and also face more barriers to accessing safe, appropriate, comprehensive care. In a talk on integrative healthcare for transgender populations, during the American Psychiatric Association’s 2018 Annual Meeting, held in New York, New York, Hansel Arroyo MD, director of psychiatry and behavioral medicine at the Institute for Advanced Medicine at the Center for Transgender Medicine and Surgery at Mount Sinai Hospital, discussed the Institute’s approach to addressing mental health needs in the delivery of care.

Arroyo began by explaining how little medical school students typically learn about the transgender population; in 1992, US medical schools typically dedicated fewer than 4 hours to education on LGBT issues. In 1998, that average dropped to below 3 hours. By 2011, very few strides had been made, with only 5 hours of education. “[This is] pretty impressive when you think of 4 years of medical school and residency; 5 hours is nothing.”

Furthermore, these hours of education focused on the LGBT community “clumped as a monolith,” so the education provided was not necessarily transgender specific, and such key topics as mental health, affirming surgery, and the coming-out experience received very little attention.

However, says Arroyo, when medical education increases clinical exposure to LGBT patients, students exhibit more willingness to treat these patients; simple curricular interventions, he said, can lead to changes in students’ knowledge and beliefs about transgender people.

Despite these strides in physician awareness, there are still marked health disparities in the transgender population. The US Transgender Survey¹ found that 39% of transgender respondents were currently experiencing serious psychological distress, versus 5% of the general population. Furthermore, 13% reported that 1 or more mental health providers had tried to stop them from being transgender. Those who were exposed to any type of aversion therapy were more likely to have experienced distress or even have run away from home.

Additionally, Arroyo estimated that the suicide rate among transgender people is 8 times higher than that of the general population, and research has demonstrated that 45% of patients who committed suicide had seen a primary care provider in the past 1 month.

Violence and legal challenges are also serious problems for transgender people; pervasive discrimination, sex-segregated discrimination, difficulty changing gender identity in government documents, housing discrimination, harassment by government agency staff, police harassment, and refusal of medical care are all issues that Arroyo’s patients have experienced.

In light of these alarming disparities, psychiatrists, said Arroyo, need to “create environments that are not only supportive, but also celebrate the transgender experience,” and provide basic healthcare, including cancer screening and HIV care.

At the Center for Transgender Medicine and Surgery, Arroyo and his team provide integrated, comprehensive health services, including primary care, specialty care, social services, legal services, and surgery. The patient pathway includes referral to a social worker who determines patient needs, a referral to specialty care—including mental healthcare—where a plan is created to address the patient’s individual needs, including possible surgery.

Among the mental health services provided are presurgical evaluations, individual psychotherapy, supportive therapy, cognitive behavioral therapy, insight-oriented therapy, relationship therapy, and pharmacotherapy.

In creating supportive environments, psychiatrists should, said Arroyo, avoid using titles like “sir” or “ma’am,” use gender neutral pronouns, and ask about an individual’s current gender identity as well as sex assigned at birth. Inclusive forms, a nondiscrimination policy, staff training, and educational materials are also key.

The goals of care should be assisting people in safe and effective pathways to maximize health and psychological wellbeing, and helping people to achieve long-term comfort with their gender identity. The goal should never, Arroyo emphasized, be intended to alter a person’s gender identity.

In addition to mental health services, the Institute provides the following treatment modalities, which Arroyo described as patient-led:

• Puberty blockers to suppress puberty at Tanner stage II; hormone therapy can start at age 16, and surgery typically takes place at age 18 or older
• Feminizing therapies, such as estrogen and antiandrogens
• Masculinizing therapies, involving testosterone
• Surgery

“What happens when people don’t have access to services like this?” Arroyo asked. “People are going to go elsewhere,” often resulting in unsuccessful surgeries with poor outcomes. Yet, since 2014, these procedures have been considered medical necessities, and most surgical procedures are covered by insurance plans, Arroyo reported.

Facial feminizing or masculinizing surgeries are more regularly subject to denials of coverage, but, “for the most part, they have been covered.” However, some patients will be required to receive psychotherapy for 1 year or more before surgery can be covered, though that such requirements do not conform to current medical standards.

Finally, in order to address the ongoing need for better clinician education about how to best treat transgender populations, the Institute, Arroyo reported, has recently created the United States’ first transgender psychiatry fellowship designed to train an individual in the range of aspects related to transgender mental health care after psychiatry residency.

Reference

1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Ana M. The report of the 2015 US transgender survey. 2016. transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Accessed May 6, 2018.