Mental Health

Highlights

Most transgender patients experience transphobia that contributes to the increased prevalence of anxiety, depression, and suicidality.
Studies have shown that rates of psychiatric disorders decrease over time in patients who undergo treatment for their gender dysphoria.
Older patients who did not undergo transition at a younger age may experience intensified gender dysphoria as they age and should be considered for both medical and surgical management if desired.
A variety of specialists can meet the criteria for a mental health professional. All professionals must have prior training in mental health and gender disorders and be capable of teasing out related and co-exisiting disorders.
Consideration of psychotherapy is recommended for all patients who identify as transgender to provide them with an opportunity to explore gender identity, role, and expression and to enhance social and peer support, improve body image, and promote resilience.

Overview

Psychological Stress and Disorders in the Transgender Population

Transphobia is thought to play a key role in mental health disparities among gender non-conforming individuals. Transgender individuals face both external stigma in the form of prejudice and discrimination from others as well as internalized transphobia – stigma that is taken on and directed at oneself. Both types of stigma can interfere with daily functioning and contribute to psychological distress and suicidality. Discrimination can increase the risk of depression, anxiety, and substance use.

Studies have shown that that there is a higher prevalence of psychiatric disorders in the transgender population, up to an 80% lifetime risk. Mood and anxiety disorders are the most common psychiatric conditions found in transgender patients while rates of more serious psychiatric disorders such has schizophrenia and bipolar disorder have not been shown to be more common compared to the general population. Most studies comparing trans men and trans women have not found a difference in the prevalence of psychiatric disorders. However one study found these disorders more prevalent in trans women compared to trans men.

Risk factors for psychiatric disorders among the transgender population include: victimization (social stigma, discrimination, transphobia, sexual abuse, gender abuse), difficulties accessing health care and social services, gender, and interpersonal problems.

Protective factors from psychiatric disorders include: social and parental support, completed medical transition, and disclosure of transgender identity.

Studies have also shown that over time (i.e., with treatment), rates of psychiatric disorders decrease and become similar to the prevalence in the general population.

Overall, transition improves the symptoms of dysphoria and quality of life in ~80% of transwomen and transmen. Endocrine therapy is associated with a significantly better quality of life, greater self-esteem, better mood, and reductions in psychological distress. Regret about gender transition is uncommon, (2.2% in one Swedish study, with regret least likely among those who commenced transition in the current era).

Being transgender is not, in and of itself, a permanent disability. However, gender dysphoria combined with the ubiquity of cissexism and transphobia in the workplace can negatively impact a patient’s transition and lead to an unsafe working environment. While often times a social/medical transition will alleviate some of this stress, in challenging cases it may be appropriate for a client to leave work. Here is a template for a letter of support for patients applying for Employment Insurance if they have left work with “just cause”.

Elderly Transgender Patients

Transgender individuals who undergo transition earlier in life are usually able to consolidate their identity by middle to late adulthood. As these individuals age, they face the same issues as other elderly people. For individuals who have not transitioned early, late adulthood can be a particularly difficult time in their life. Isolation, shame, lack of support, and regrets about the passage of time, can cause distress in previously stable individuals.

Individuals who present to physicians in middle age, should be made aware that gender issues often intensify with age. Mental health professionals who work with this population must be aware of the potential for “ageism” – their own preconceived belief that one may be “too old” to make various life changes. Patients who are healthy may benefit from medical and surgical interventions, even at later decades of life.

Mental Health Professionals

A mental health professional’s assessment and referral is required for hormonal or surgical management. Mental health professionals (MHPs) could come from many different backgrounds including psychology, psychiatry, social work, or family medicine, but should have specialty training in dealing with gender dysphoria.

Minimum credentials for MHPs to work with individuals with gender dysphoria are as follows (WPATH):

A master’s degree or its equivalent in a clinical behavioral science field. This degree or a more advanced one should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country;
Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes;
Ability to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria;
Documented supervised training and competence in psychotherapy or counselling;
Knowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria;
Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

Psychotherapy

While a mental health assessment (as outlined above) is required prior to referral for hormones or surgery, psychotherapy is not. However, psychotherapy is highly recommended by the WPATH, although no minimum number of sessions is suggested.

The goal of psychotherapy is to maximize a person’s psychological well-being. In some individuals, psychotherapy may allow them to integrate their transgender feelings into the gender role they were assigned at birth and they will not feel the need to feminize or masculinize their body. However, treatment trying to change an individual’s gender identity has been attempted unsuccessfully in the past and is no longer considered ethical. Psychotherapy allows the individual an opportunity to explore gender identity, role, and expression. It also allows individuals to address the negative impact of gender dysphoria and stigma on mental health and to enhance social and peer support, improve body image, and promote resilience. Psychotherapy may consist of individual, couple, family, or group therapy.

Support groups

Support groups can be helpful for many transgender patients as they provide patients with a network of individuals that can relate to their situation and support them through their transition. Support groups can also be helpful for the family and close friends of transgender patients by helping them to understand, accept, and support their loved one’s gender identity.