Psychiatrists are uniquely positioned to care for transgender and gender nonconforming (TGNC) patients due to their understanding of the intersections between biologic, psychologic, and social factors of presentation, as well as complex systems of care. However, psychiatrists generally lack training and experience in working with transgender people. In addition, a history of pathologizing and gatekeeping in decades past has led many TGNC people to avoid psychiatrists. Yet, any accepting and affirming psychiatrist willing to challenge their own beliefs about gender can learn to work effectively with this population.
TGNC patients should be treated as any other patient presenting for care. Evaluation should include a chief complaint, history, mental status examination, formulation, diagnosis, and treatment plan.1 TGNC patients may present with gender identities, bodies, medical histories, and/or sexual histories that are unfamiliar to some clinicians. This can provoke clinician anxiety and discomfort that comes with any unfamiliar situation, particularly those that challenge one's own ingrained belief systems about gender and sexuality. It is especially important to consciously avoid bringing one's own beliefs into the therapeutic relationship with transgender people due to risk of unintentionally offending or retraumatizing the person, as transgender people experience societal micro-aggressions on a daily basis and, more likely than not, have experienced more overt prejudices or victimization as well. Therefore, psychiatrists should pursue training, supervision, and possibly their own therapeutic treatment to work through conscious and unconscious conflicts that may negatively affect their work with this population.2
TGNC people present to all treatment settings: acute psychiatric emergency rooms, inpatient units, medical floors served by psychiatric consultants, outpatient clinics, and private practice settings. It is essential, as with any patient, to identify the reason for the evaluation, locate the source of distress, ascertain a hierarchy of needs, and formulate an individualized treatment plan. It is important to ascertain if and how gender dysphoria, gender nonconformity, or transgender identity play a role in the presenting complaint. Sometimes this is obvious, as a patient may state it up front. Other times it may not at first be obvious to the patient but may become evident to the clinician and patient as treatment proceeds. It is important to be supportive yet relatively neutral; to avoid pathologizing assumptions, behavior, and language; and to work to maintain an empathic, open stance.3
All the features of the psychiatric evaluation appropriate for the specific clinical setting of presentation should be completed. This starts with assessing why the patient is presenting. TGNC people may be looking urgently for help in resolving gender dysphoria through transition, may be suffering from symptoms associated with gender dysphoria (anxiety, depression, paranoia, suicidality), or may present with mental illness that is unrelated to gender dysphoria or TGNC identity. For example, some TGNC people may present with no gender dysphoria or be many years post-transition with no desire to revisit that part of their life, whereas others may present in various stages of transition with gender dysphoria that is unrelated to their presenting complaint and symptomatology. It is important to establish if gender dysphoria exists and to not assume that it does. Many TGNC people do not suffer from ongoing gender dysphoria.1
It is helpful to ascertain the degree of identity consolidation and how the patient copes with areas of distress, including those related to gender presentation and identity. The clinician should evaluate for features in patients' social, occupational, and family and educational settings that stress them and are lacking in support. Assess for areas of resilience and vulnerability. Evaluate for history of trauma, including physical, emotional, sexual, medical, and psychiatric. Pay particular attention to forms of gender trauma, including abuse, that may have occurred in a treatment setting, as well as experience with bullying, discrimination, micro-aggression, and minority stress. It is especially important to identify if the patient is likely to distrust psychiatrists due to past mistreatment or perceived philosophical or political differences. Remain attuned to this in the interest of maintaining a positive treatment alliance.
A TGNC person may present for psychiatric care solely for the purpose of pursuing gender-related services or interventions. Evaluation for hormones and/or surgical procedures indicates a patient has some degree of certainty and feels they are ready to move forward with the transition. Other patients may present with less certainty or even a high degree of uncertainty. In these cases, psychiatrists can support their path of exploration, which may involve referral to an appropriate therapist, group, or social service agency. Psychiatrists who are skilled at psychotherapy may choose to work with the patient to explore their options, challenges, conflicts, and decisions.
TGNC adults can reside anywhere on the gender spectrum. Popular media have recently publicized high-profile transitions of celebrities, such as Caitlyn Jenner, with a focus on the transition from one discrete gender to the polar opposite end of the spectrum, where hormones and surgery are used to modify the body to fit a binary gender identity. However, many TGNC people fall in a range of mixed, fluid, or nonbinary gender identities. TGNC people may or may not choose to modify their bodies through hormones or surgery, or may employ combinations of hormones and/or surgeries that do not align rigidly with the binary gender framework. They may seek nonmedical forms of body modification, or no body modification whatsoever.4
There are many aspects to social transition, including change of name; coming out to friends, family, and coworkers; seeking support, respect, and recognition of identity; and changing identification documents. The TGNC patient can benefit immensely when supported through these experiences in a collaborative treatment with a psychiatrist. Psychiatrists working with TGNC patients should educate themselves about the local laws related to name and gender change on birth certificates and driver's licenses, and the specific language required for supportive letters from a physician required to change these identity documents.
There are several successful hormonal treatments for transgender people who choose hormone therapy, but none of them are approved by the US Food and Drug Administration for this indication. Hormone regimens are usually prescribed by endocrinologists, primary care physicians, or primary care nurse practitioners. World Professional Association for Transgender Health (WPATH) Standards of Care4 and the Endocrine Society Clinical Practice Guidelines5,6 present up-to-date, peer-reviewed guidelines for prescribing hormones.
Gonadotropin-releasing hormone analogues can be used in adolescents to delay unwanted puberty and secondary sex characteristics not aligning with one's gender identity. They can also be used to initiate hormone transition in adults to suppress the hypothalamic-pituitary-adrenal axis and sex hormone production before the start of cross-sex hormones. Not all clinicians prescribe analogues, mainly because of the prohibitive cost. Transgender women (male to female) are often prescribed androgen blockers such as spironolactone, in addition to feminizing hormones, most commonly estradiol. Some transgender women also take progesterone, although there is controversy as to whether it has added benefits to estrogen. Transgender men (female to male) are prescribed testosterone. These hormones are usually taken indefinitely, have reversible and irreversible effects, desired physical effects, unwanted physical effects, and sometimes emotional side effects. Psychiatrists should become familiar with the common physical and emotional effects. In addition, psychiatrists should be aware of common drug-drug interactions between hormonal treatments and psychiatric medications. For example, concurrent use of lithium and spironolactone can result in increased lithium levels and result in lithium toxicity. Lamotrigine doses may need to be significantly increased while on estrogen to reach therapeutic levels.7
Desired hormonal effects for transgender women include softening of skin, decreased ratio of muscle to fat mass, breast growth, and decreased testicular size. Potential adverse effects include venous-thromboembolic events, hypertension, liver dysfunction, weight gain, hyperprolactinemia (rare), diabetes, and dyslipidemia. Antiandrogens and estrogen can also decrease libido, which can be a wanted or unwanted side effect. Smoking cessation is important to decrease risk of venous-thromboembolic events, although tobacco use is not an absolute contraindication to estrogen use, and should be an area of discussion and possible treatment. If progesterone is used, monitor for depression, as lower mood is not uncommon.
Desired hormonal effects for transgender men taking testosterone include cessation of menses, growth of facial and body hair, deepening of voice, increased ratio of muscle to fat, changes in distribution of body fat, and facial masculinization. Potential unwanted effects include acne and male-pattern balding. There is usually an increase in libido when taking testosterone, which can be either pleasurable or discomforting depending on the person. Clitoral growth is often a source of improved self-esteem, although it can also be physically painful for some and psychologically challenging for those who experience genital dysphoria. Adverse effects of testosterone include hypertension, polycythemia, weight gain, dyslipidemia, and the possible unmasking of sleep apnea. Transgender men taking testosterone may experience increased energy, strength, and possibly aggression.1,4,5
Although hormones can affect emotions, the doses and regimens typically used do not lead to major emotional problems. Supraphysiologic hormone levels (more likely if someone is taking hormones obtained on the street or Internet, or taking more than prescribed dosages) increase risk for aggression, mood, and psychotic symptoms. There are rare documented cases of psychosis after sudden cessation of estradiol in transgender women and some reports of depression at the start of feminizing hormones.8 Reduction in testosterone in transgender women has been associated with worsening mood, although it is more common for transgender women to report subjective mood improvement when starting hormones. Emotional changes should be expected to be subtle and congruent with a person's pretransition personality. Psychiatric symptoms that raise concern include heightened impulsivity, lability, extreme dysregulated affect, violent ideation, frequent and/or severe dissociation, suicidal ideation, and psychotic symptoms. The psychiatrist should take a harm reduction approach that factors in all symptoms, including gender dysphoria, and the need for relief and optimal management. It is usually not appropriate to delay hormones or to withhold them with the expectation that the patient must “get better.” Psychiatrists run the risk of making their own anxiety the object of treatment at the cost of harming the patient.1,9
Clinicians and patients should be aware that transition may lead to changes in patterns of sexual attraction and orientation, which may be related to effects of hormones, changes in physical body, and increased acceptance of one's gendered body.3,10 Although this can be a positive experience for many, it can also be a source of confusion and relational disturbances for others. Clinicians should support patients in learning about new risks that may arise from changes in sexual behavior, such as sexually transmitted infections, HIV, and pregnancy.
For any patient undergoing hormone suppression via medical or surgical (gonadectomy) intervention, there is risk for a decrease in bone mass over time, making eventual use of cross-sex hormones or reversion to an unsuppressed hormone milieu desirable for optimal bone health.5
Any patient undergoing hormonal therapy or genital surgery should consider loss of reproductive function and options to preserve gametes. Options include postponing medical interventions, as well as freezing sperm or fertilized eggs. Transgender men using testosterone may be able to stop testosterone and become pregnant, although this is not a guarantee.4
Informed Consent Model
Over the past decade, many lesbian, gay, bisexual, and transgender (LGBT) community health clinics that serve large numbers of TGNC people have employed an “informed consent model” for access to hormone treatment. Rather than being required to see a mental health provider, the patient meets with a trained clinical staff member, reviews the risks and benefits of treatment, and participates in a mental health screening.11 Psychiatrists may encounter patients who choose this route rather than requesting a traditional letter, because it is no longer routinely required by expert guidelines. There are potential benefits to this arrangement as well as potential risks. Although using informed consent is a clear benefit to the transgender community because it lowers barriers to access and prevents problems encountered in the era of the “gatekeeper,” there is a risk that mental health problems that are not obvious to the screener and not disclosed by the patient may go undetected. Regardless of which approach is used, it is optimal for the patient to have access to both needed hormonal treatment and quality mental health care.
Letters for Hormone Therapy and Surgery
If a patient requests a letter for hormone therapy there are four main criteria that must be met, as per the WPATH4: (1) persistent, well-documented gender dysphoria; (2) capacity to make a fully informed decision to consent for treatment; (3) age of majority in given country; and (4) if significant medical or mental health concerns are present, they must be reasonably well controlled. A letter should include identifying characteristics; psychosocial assessment results, including diagnosis; the duration of clinical relationship; the type of evaluation or therapy; an explanation that the criteria for hormone therapy have been met; a brief description of rationale for supporting the client's hormone request; a statement that informed consent has been obtained; and a statement that the referring clinician is available for coordination of care.4
Not all clinicians are comfortable writing letters for patients. For instance, psychoanalytic therapists and/or therapists with limited experience working with TGNC people may feel uncomfortable or unqualified. Some prefer to refer patients to gender specialists, which may be acceptable or objectionable to the patient. Referral to a specialist can simplify the therapy in some respects, by removing the potential “gatekeeper” role. However, for patients who have undergone a long-term therapy and have concluded that transition is the best step, referral to another therapist can be problematic for transferential as well as logistical and economic reasons.
There are various surgical options for those TGNC people who desire them. Available surgical procedures for transgender women include penectomy, orchiectomy, vaginoplasty, and breast augmentation. Some may choose to undergo a tracheal shave and/or facial feminization surgery. Available surgeries for transgender men include double mastectomy and chest contouring (“top surgery”), hysterectomy-oophorectomy, metoidioplasty, and phalloplasty (the latter two are genital reconstructive surgeries or “bottom surgeries”). Phalloplasty is relatively uncommon in the United States because of the prohibitive cost, as well as the degree of risk and suboptimal efficacy of current technology. Some transgender men also pursue vaginectomy and scrotoplasty.
It is important to consider the irreversibility of any surgery and to help patients explore their decisions fully. This includes preparing themselves for optimal self-care and recruiting their support system to care for them during recovery. The consequences of genital surgery can involve changes in reproductive capacity, intimate sexual sensation, urinary tract outlets, and self-care (ie, vaginal dilation after vaginoplasty). Because of the higher cost and risk of genital surgeries, WPATH4 suggests that patients have letters from two separate mental health providers who have evaluated them: one from a primary provider and a second from an independent evaluator. Nongenital procedures require just one letter, meant to ensure informed consent is possible and that there are no severe psychiatric symptoms or syndromes that actively contraindicate surgery along the path and timing proposed by the patient.
Hormone therapy is not a prerequisite for transgender men undergoing top surgery, but 12 months of hormone therapy is recommended (not required) for transgender women prior to breast augmentation as this will maximize the chance for breast growth.
The WPATH4 criteria for transgender men undergoing hysterectomy-salpingo-oophorectomy and transgender women undergoing orchiectomy suggest that the patient experience 12 continuous months of hormone therapy as appropriate to the patient's gender goals (unless hormones are not indicated or desired). The criteria for genital surgery also suggest 12 continuous months of living in a gender role that is congruent with gender identity prior to surgery. These are not requirements, but suggestions based on available evidence and expert consensus; they do not apply to all patients and may vary based on situation.
Psychotherapy has historically played a controversial role in the care of transgender people because it was a forum in which gatekeeping, abusive power dynamics, and contra-therapeutic fabricated narratives would often unfold. Not too long ago, and likely still in some consultation rooms, TGNC patients seeking transition were forced into “real transsexual” criteria to prove themselves worthy of hormonal and surgical transition. For instance, some clinicians acting as gatekeepers approved only those patients whose transitions would result in heterosexual outcomes, and used their own subjective bias regarding norms of gendered behavior and appearance to govern decisions about access to hormones and surgery.12 That era in psychiatry and psychoanalysis was harmful to TGNC people because it made therapy a farcical obstacle course to get through rather than a safe, open exploration. TGNC people should be able to seek out therapy to truly help them through difficult periods of life, without the specter of needing to fit arbitrary or overly burdensome criteria to open a tightly guarded gate to transition.
In the past, TGNC people were even more traumatized by “reparative” or “conversion” therapies, a religiously based intervention no longer supported in clinical practice.
WPATH,4 the American Psychiatric1 and Psychological Associations,13,14 and the American Psychoanalytic Association15 warn against using psychotherapy to attempt to convert a person out of their transgender or gender nonconforming identity. “Conversion therapy” with gay and lesbian patients has been well studied and is known to be harmful.16 Some of the most blatant and harmful tactics in those practices attempt to manipulate gender expression and behavior to the detriment of the patient's well-being. The known negative effect of those tactics and the high rate of suicide in TGNC people forced to suppress or hide their identity demonstrates the potential severe harm that can occur when an influential clinician or figure tries to change a person's gender identity.
The types of problems that legitimate psychotherapy can help a TGNC person address include, but are not limited to, identity consolidation; coming out; whether and when to transition; making decisions about hormones and surgery; and navigating dynamics and problems in families, employment, and education. There is also a need for therapists to work with family members who may have difficulty adapting to a loved one's coming out and/or transition.1,3,4,6
Psychotherapy is a place to explore identity and options. Paths to transition are different for everyone, and creating a safe and sound path requires patience and support. Some patients have conflicts over identity and need to work this out in psychotherapy. Various forms of individual psychotherapy—supportive, psychodyamic, interpersonal, cognitive-behavioral therapy, and dialectical behavioral therapy—can foster resilience, insight, and new coping mechanisms that allay symptoms.
Group psychotherapy, which may or may not be trans-specific but should be trans-affirming, is more appropriate for those who best learn and gain support from a group. Some community centers offer both drop-in and closed trans-specific support groups. TGNC people who are especially isolated may use these groups as their sole support system while going through a transition. The Internet provides wide access to TGNC stories, often through YouTube videos, blogs, and social media. Although these platforms offer significant domains for support and exploration where the anonymity and egalitarian quality can be liberating, there is a risk of cyberbullying and false information.
It is no longer a requirement according to WPATH4 that a specific trial of therapy be completed before pursuing transition with hormones or surgery. However, there is evidence that presurgical psychotherapy contributes to positive postsurgical outcomes.1 WPATH4 endorses and encourages the use of therapy as a means of support, managing complex feelings, and working through external and internal conflicts prior to and during transition. WPATH4 specifically recommends follow-up with a mental health clinician or medical provider after genital surgery. Some transgender people may struggle during transition with the loss of significant relationships, including a spouse or long-term partner. Some face new challenges dating safely in a changing body and consolidating identity. Others must deal with workplace transphobia, even changing jobs or career. Transition can be a time of minor or massive flux, and the presence of a therapeutic holding space that encourages and supports reflection with a trusted therapist can foster a smooth and successful transition.
Aside from transition, TGNC people face the regular strains of life (relationships, health problems, financial issues, and aging), albeit often with an added complexity that stems from being a gender minority. It is important to provide appropriate therapeutic help that does not negate, pathologize, or overly privilege the impact of trans identity.
The field of psychiatry is experiencing an increase in the number of patients who identify as TGNC and/or gender questioning. Psychiatrists have much to offer and can contribute to improved mental health in transgender people.
- Byne W, Bradley S, Coleman E, et al. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759–796. doi:10.1007/s10508-012-9975-x [CrossRef]
- Hansbury G, Pula J, Sakeopoulou A. Conceptual, technical and countertransferential difficultues in working with transsexual and transgender analysands. Paper presented at: Meeting of the International Psychoanalytic Association. ; July 24, 2015. ; Boston, MA. .
- American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. http://www.apa.org/practice/guidelines/transgender.pdf. Accessed April 5, 2016.
- Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender nonconforming people, version 7. Int J Transgend. 2011;13:165–232. doi:10.1080/15532739.2011.700873 [CrossRef]
- Hembree W, Cohen-Kettenis P, Delamarrevan de Waal H, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–3154. doi:10.1210/jc.2009-0345 [CrossRef]
- University of California, San Francisco. Primary care protocol for transgender patient care. http://www.transhealth.ucsf.edu/tcoe?page=protocol-00-00. Accessed April 4, 2016.
- Reddy DS. Clinical pharmacokinetic interactions between antiepileptic drugs and hormonal contraceptives. Expert Rev Clin Pharmacol. 2010:3(2):183–192. doi:10.1586/ecp.10.3 [CrossRef]
- Bockting W, Knudson G, Goldberg J. Counseling and mental health care for transgender adults and loved ones. Int J Transgend. 2006;9(3):35–82. doi:10.1300/J485v09n03_03 [CrossRef]
- Karasic D. Transgender and gender non-conforming patients. In: Lin R, ed. Clinical Manual of Cultural Psychiatry. 2nd ed. Washington, DC: American Psychiatric Publishing; 2014:397–409.
- Meier SC, Pardo ST, Labuski C, et al. Measures of clinical health among female-to-male transgender persons as a function of sexual orientation. Arch Sex Behav. 2013:42(3):463–474. doi:10.1007/s10508-012-0052-2 [CrossRef]
- Deutsch M. Use of the informed consent model in the provision of cross-sex hormone therapy: a survey of the practices of selected clinics. Int J Transgend. 2012;13:140–146. doi:10.1080/15532739.2011.675233 [CrossRef]
- Meyerwitz J. How Sex Changed: A History of Transsexuality in the United States. Cambridge, MA: Harvard University Press; 2002.
- American Psychological Association. APA Applauds President Obama's Call to End the Use of Therapies Intended to Change Sexual Orientation. http://www.apa.org/monitor/2015/06/upfront-therapies.aspx. Accessed April 29, 2016.
- American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70:832–864. doi:10.1037/a0039906 [CrossRef]
- American Psychoanalytic Association. 2012 - Position statement on attempts to change sexual orientation, gender identity, or gender expression. http://www.apsa.org/content/2012-position-statement-attempts-change-sexual-orientation-gender-identity-or-gender. Accessed April 29, 2016.
- APA Task Force on the Appropriate Therapeutic Response to Sexual Orientation. Report of the Task Force on the Appropriate Therapeutic Response to Sexual Orientation. Washington, DC: American Psychological Association; 2009.