Welcome to the American Psychiatric Association's Looking Beyond webinar series. My name is Dr. Gabriel Contreras, Jr., and I am the Managing Director in the Division of Diversity and Health Equity. Before we get started, I want to take this opportunity to thank our APA President, Dr. Brindow, our CEO and Medical Director, Dr. Levin, the APA Board of Trustees, councils, especially the Council on Minority Mental Health and Health Disparities for helping us organize this session today, our assembly, caucuses, and administration for their continuous work and support in advancing mental health equity. Today, our topic of discussion is LGBTQ plus mental health, challenges, advocacy, and clinical considerations for transgender and gender nonconforming persons. Our panelists will discuss mental health inequities affecting transgender and non-binary people and provide strategies for incorporating evidence-based, affirming mental health care into clinical psychiatric practice. To set the stage for the webinar, I'll be passing the virtual mic to our moderator, Dr. Amir Ahuja, but first, a little bit about Dr. Ahuja. Dr. Ahuja is a board-certified psychiatrist and fellow of the APA. He has treated thousands of patients over the years in a variety of settings. He has a wide experience in dealing with many different communities and conditions. Currently, he is a leading voice for the LGBTQ plus community. As the Director of Psychiatry at the Los Angeles LGBT Center, the largest LGBT center in the world, he oversees a team that sees over 2,500 patients. In addition, he is the president of the AGLP, the Association of LGBTQ plus Psychiatrists, the nation's leading organization for LGBTQ plus healthcare providers and their patients. Dr. Ahuja has been in private practice and is currently in Burrill Hills, California. He offers psychiatric medication and adjustments in a range of therapeutic techniques. He was taught for years by a former president of the National Association for CBT and completed a two-year course in psychodynamic psychotherapy in Philadelphia. He is comfortable using either of these therapeutic techniques. And now, please welcome Dr. Amir Ahuja, who will now give you a little bit more briefing about the session today, in addition to introducing the panelists. Welcome, Dr. Ahuja. Thank you, Gabriel. I'm really happy to be here with all of you this evening. We are really excited to have this webinar and to be invited to have done this as a beginning of a conversation about LGBTQ plus psychiatry, psychiatrists and their patients. And we really are dedicated to having this be the opening of a conversation. This was conceptualized as the first of several, hopefully, webinars that we can have where we can have a lot of conversations on a longitudinal basis regarding the mental health of vulnerable populations. And I know that the APA is very committed to health equity and mental health equity in particular. So we're hoping that this furthers that goal. For this webinar, this is our first one. So we're trying to lay the groundwork for understanding transgender and non-binary or gender non-conforming mental health. And to help me do that, we have several great speakers here today. Now, I just wanted to mention before we get started that I am part of the Council of Minority Mental Health and Health Disparities, and they've done a lot of work to help us get this together. I wanna give special thanks to Walter Wilson and Shane Collins who both were instrumental in putting this together, as well as the caucus. I'm the president of the caucus of LGBTQ psychiatrists and the APA, and the caucus is certainly very helpful as well in putting this together. And most of us are in this call and in this talk are members of both AGLP and the caucus. So thank you for that. So the way this is structured is that we'll each be talking for 15 minutes. And then we have three presentations that are 15 minutes in length about, and then we will do a Q&A at the end. So there is a chat function where you can type in your questions and we are happy to answer all of your questions. Again, given that this is the first one of hopefully several webinars, we're sort of starting with foundational elements to this and we wanna make sure that your questions are answered. So if you do have any questions at all, don't feel shy to put them down and we'll do our best to answer all of them. And no question is too simple or something that we won't consider. So please be as earnest as you can and in asking your questions. In terms of the presentations, I just wanted to kind of go over the way that we're gonna be doing this. So obviously this is the introduction, then we'll have first a talk on transgender and non-binary mental health, basic education and statistics. Then we'll go into clinical considerations for gender affirming care. And finally, current issues impacting the mental health of LGBTQ plus persons, followed by the end being the question and answer session. So I will introduce the panelists. What I will do after that is we have some CME questions that we're kind of wanting everyone to answer. So after I do the introductions, I'm going to have those questions pop up so that you all can answer them. And when we come back at the end during the Q&A, we can kind of go over those answers and kind of see what we've learned and what misconceptions we might have had, if any. So let me start with the panelists in order. So first we have Dr. Fiona Fonseca who will be doing the first presentation. Excuse me, they are a Consultation Liaison Psychiatry Fellow at the Mayo Clinic in Rochester, Minnesota. Their current fellowship includes a focus on transgender and reproductive medicine, as well as electives in neuromodulation and HIV medicine. Their professional interests also include cultural psychiatry, medical ethics, psychotherapy and advocacy for their patients and profession. Upon completion of the fellowship year, Dr. Fonseca will continue on from Mayo Clinic as a Senior Associate Consultant in the psychiatry department, working closely with the transgender and intersex specialty care clinic, the TISCC, while pursuing a further training in clinical and translational research. And Dr. Fonseca is also the APA AF SAMHSA Fellow and Diversity Leadership Fellow, excuse me. So we really appreciate their service in the APA. So thank you so much, Dr. Fonseca for being here. The next person who will present is Dr. Teddy Goetz, who is a psychiatry resident at the University of Pennsylvania. Prior to earning their MD at Columbia, they studied biochemistry and gender studies at Yale, conducting research on a wide spectrum of biologically and socially determined aspects of gender-based health disparities, including earning their MS, developing the first animal model of gender-affirming hormone therapy. They have two forthcoming books entitled Gender-Affirming Psychiatric Care for Transgender and Gender-Diverse People, the first textbook on gender-affirming psychiatric care being done by APA Publishing and coming out in 2023. And Gender is Really Strange, a graphic novel about the rich complexities of gender, sociocultural to neuroscience. Their current focuses include mixed methods research on LGBTQ mental health, as well as narrative medicine physician advocacy. More about their scholarly and artistic work can be found at teddygoetz.com. And that's T-E-D-D-Y-G-O-E-T-Z.com. Finally, we're thrilled to have Laura Erickson-Schroth. And they are a psychiatrist committed to improving mental health through education and resource creation. They are the chief medical officer at the Jed Foundation, a nonprofit focused on emotional health and suicide prevention for teens and young adults. Laura has provided thousands of patients with crisis intervention and mental health support in over 10 different emergency rooms in New York City. Much of their career has focused on LGBTQ mental health, and they continue to see clients at Hendrick Martin Institute for LGBTQIA plus youth. Laura is editor of Trans Bodies, Trans Cells, which was first published in 2014 with a second edition in 2022, which is a resource guide written by and for trans communities. So we're thrilled to have all three of these panelists. As I said, I do want to open up the poll so that we can all take that poll for the CME questions kind of as a pretest. And I will give everybody a couple minutes to do that while we wait to do the first presentation. So we will go over those results and when we are able to get that going, we will go over them at the end. So just whenever they show up, I think they're here, you can answer those. In the meantime, we'll start. So our first presentation, as I said, is about statistics as a transgender and non-binary mental health, basic education and statistics. So I will hand over the virtual mic to Fiona for that. All right, and who's doing the screen share for the slides? I'll turn off my camera here so we can all focus on the information on the screen. Welcome, everyone. So my task here will be to tee things up for our amazing panelists coming up and just do kind of a brief 101 on health issues, specifically mental health issues for our trans and gender diverse folks. If we can move to the next slide. In terms of financial disclosures, I have no conflicts to disclose and I have used some images and they are all stock photos except for ones where there is an acknowledgment in the bottom. We can move to the next slide. So trans and gender diverse folks have always been here and, next slide, are still here and that is why we are talking about working with this community, working with my community too. So when we do talk about this, I think there are oftentimes a lot of stereotypes that maybe we hold on to as mental health professionals, as members of the society that does have certain narratives underlying our cultural context. But also thinking about how certain populations may be more vulnerable and taking a look at some of the numbers here, we can move to the next slide, specifically a large EHR study that was carried out by Wanta et al. in 2019 that looked at over 10,270 trans individuals. We did have some numbers that were quite concerning in terms of mental health diagnoses for trans and gender diverse individuals versus cisgender individuals. If we move to the next slide, we can see what specifically really stands out for us here. And what we are looking at is a percentage of individuals who have been given these diagnoses versus the percentage of cisgender individuals who have been given these diagnoses and then further breaking it down, you see this large disproportion where there is an overrepresentation of depression, anxiety, a lot of trauma, adjustment disorders, personality disorders, something that again, specifically they looked at borderline personality disorder that was overrepresented, eating disorders, ADHD, autism, substance use disorders, tobacco use, and particularly in transmasculine individuals and trans men, use of alcohol, THC, nicotine, and then in trans women and trans feminine individuals, use of stimulants and IV substances. A large proportion of individuals had at least one diagnosis. So if we can click to the next slide and then do a few clicks for me, because I have some animated things in there. There we go. So we talk about what makes a diagnosis beyond thinking about like the DSM, the APA, cluster of symptoms of forming disorders. To actually create a diagnosis, you have to have three different factors. You have the individual walking into the room, bringing in their world. You have the clinician and their worldview, their cultural lens and their biases. And then you have the environment that all of that is contextualized within. And when we think about the numbers on the previous slides, I want us to just keep in mind that those numbers are not just about the patients and the representation of the proportion of diagnoses within the population, but it's also about what the clinicians bring into the room, who they may be more or less likely to diagnose with certain conditions, and then the environment, the setting, the cultural context. Next slide, please. So we just had the 2022 U.S. Transgender Survey, and we don't have the data from that quite yet, but the most recent iteration prior to that was from 2015, and it looked at over 27,000 transgender adults living in the U.S. And if we just do a little click. Out of that population, over a third reported having at least one negative experience with a health professional, where they were either discriminated against, had to educate the professional about things, or were not able to access care. If you could go to the next slide, please. About half of them needed to teach clinicians about providing appropriate care. A third reported negative experiences, a quarter reported being turned away, and a quarter reported problems with insurance. Now, I do want to point out that according to health care rights law, insurance companies cannot exclude trans health or charge higher premiums or put on any discriminatory limits on accessing care. But some of these rights to basic health care are being challenged in this current political climate, as some of my co-panelists will talk about later today. Next slide, please. And when we think about the challenges that the transgender and gender diverse folks experience, their experience within the medical system, a lot of this boils down to medical mistrust and minority stress. And next slide. When we talk about medical mistrust, it's something that is culturally ingrained after years and years of discrimination and the way the system has been set up, where a lot of biases really used to justify and operationalize treatment protocols, even looking all the way back to the 70s with experiments that were NIH funded, trying to essentially attempt changes in feminine behavior to kind of modify that amongst cisgender boys. And really, that experiment was incredibly inhumane. And some of the results showed, quote, unquote, promise, and that they were able to kind of moderate some of those behaviors. But in the long term, when they did follow those individuals, they had significant depression, suicidality. So it was not a successful experiment at all. And that would not fly today in terms of being able to get funded. So we have come, we have made some leeway in terms of, some headway in terms of making progress, but we still have a long way to go. We still have a lot of talk within the literature about conversion therapy, reparative therapy efforts. And, you know, the APA really does come down against that. And we need to kind of acknowledge our role that we have played as psychiatrists, because we did traditionally diagnose and label transgender and gender diverse individuals as being mentally ill. Next slide, please. Even looking back at the DSM, we've moved from no mention in the 50s to it being a sexual deviation, the transvestism in the 60s, to a psychosexual disorder, transsexualism in the 80s, and then gender identity disorder, where the identity itself was a pathology in the 90s, to now where we finally look at as gender dysphoria, even though it is looked at as something that the individual experiences less so contextualized the way it could be as being more of a society, societally driven experience. And then within the ICD kind of parallels what was happening with the DSM there too. Next slide, please. I think this talk would be incomplete without us talking about the trans broken arm syndrome, which is when as a health care provider, you assume that all medical issues are a result of a person being trans. So someone comes in the door, they might come in with a cough that's lasted three weeks, but you start talking with them about their trans identity, when that really has nothing to do with their initial presentation. And that also can take away from being able to provide the quality of care that individuals deserve. So just because there is some sort of an association, the individual might be a member of the community, doesn't mean that their identity causes their symptoms. And it's very similar when it comes to mental health diagnoses. And it's really on us to use evidence-based medicine and good clinical judgment. Next slide. I did want to talk also about the gender minority stress model, which comes from the minority stress model where the additional stresses of being a minoritized individual overall contributes to a worsening health disparities and inequities. And that started in the 80s in terms of talking about the LGBT community with Virginia Brooks and who talked about that within lesbian women. And then with Meyer in 2003, who talked about LGB people at large, and then with Hendricks and Testa in 2012, specifically focusing on transgender and gender diverse individuals. Next slide, please. I think you might have to do a few clicks on this one. Another one. Thank you. So when we talk about minority stress, it's really important for us to think about how the individual is marginalized and kind of excluded from the general population. And this happens at three different layers. So you have discrimination, experiences of prejudice, what happened to you? Stigma, where someone is anticipating negative social attitudes. What do you think people think of you? And internalized stigma, where these negative attitudes have been internalized and absorbed, affecting self-belief. So when we talk about minority stress model, that was referred to as the distal and the proximal factors. And the distal ones would include things like discrimination, rejection, structural stigma, and so on. And then the victimization, non-affirmation, invalidation, things like that. And then the proximal factors would be things like gender dysphoria, internalized transphobia, a vicarious stress, just the mental and emotional labors of having to consistently explain oneself. Next slide, please. And when we look at that, we know that a constant stress results in a neuroendocrine response that, in time, results in negative health outcomes. Next slide, please. I also wanted us to think about intersectionality for a moment here, originally coming from Dr. Crenshaw's work, where intersectionality is a strand of kind of kind of have an understanding of the interconnected nature of social characterizations, the categorizations, really, that overlap, that are interdependent in some way. And that really are different systems of discrimination or disadvantage that kind of interact with each other and impact each other. So different layers of one individual's identity. And I mentioned that because throughout this piece, I didn't talk about physical disability. I didn't talk about age. I didn't talk about race, ethnicity. I didn't talk about sexual orientation and how that factors in or, you know, financial status and things like that. And we had the Trevor Project report come out just yesterday that showed us that over a third of Black transgender and gender diverse individuals have symptoms of depression, about three-fourths had symptoms of anxiety, and about a quarter of individuals attempted suicide within just the past year. So really, we're not just talking about transgender and gender diverse individuals, but looking at that as being yet another layer for someone. Next slide, please. So, again, coming back to this original question of what makes a diagnosis and the three factors to think about, I really want us to think about our patient's perspective, looking at intersectionality, the environmental impact, minority stress, things like that. And then your own biases coming in. But you can also have a positive impact. Next slide. And if you are affirming, what you can do is pay closer attention to health issues that affect your patients. You can learn to be affirming in the room with them using terminology, pronouns, names, language that is affirming. Refer them to other clinicians who are affirming. Better involve them in decisions, offer appropriate care and screening, help connect individuals with resources, really provide better quality care. And you can be a part of the change. And a part of the future rather than a part of the past that has been quite harmful for psychiatry. I think that might be my last slide. Yes. I'll hand it off now to Teddy. Thanks so much. So here, I think that we oftentimes as psychiatrists focus on psychiatric medications, but that's only a small part of what we can do as gender-affirming psychiatric care, really, because as research robustly shows, gender-affirming medical care and gender-affirming surgical care actually improve mental health symptoms of depression, anxiety, suicidality. And these are all things that obviously are really important to us. And it's not that complicated. So I think doing a quick whirlwind of different aspects of gender-affirming clinical care can be helpful for contextualizing all of this and seeing how we can expand our own practices within our scope of practice. Slide. So we'll be talking about briefly trauma-informed care, building on what Dr. Fonseca said, interview basics, and then some gender-affirming medical and surgical care, and then, of course, psychiatric care. Slide. So first, thinking about, again, trauma-informed care is essential for when working with transgender, non-binary, and or gender-expansive communities. Folks can use TNG, which I have here, versus TGD for transgender and gender-diverse, equally interchangeable many acronyms. We'll see what is being used in five years might be entirely different. So TNG communities face a disproportionate levels of violence and victimization, and PTSD symptoms worsen often after non-affirming experiences, which is intuitive. So conducting gender-affirming care is also conducting trauma- informed care, which involves trust and emotional safety, environmental and physical safety, choice and collaboration, and empowerment. It's also important to screen for PTSD and to treat as indicated and to be thoughtful and judicious about personality disorder diagnoses in these communities, particularly cluster B and borderline personality disorder diagnoses, which oftentimes coincide with trauma and can also be weaponized in a more apologizing way, as I'm sure you all know. Slide. So just, this is, again, reinforcing what Dr. Fontega said, but here are a couple quotes from the U.S. Transgender Survey in 2015 about experiences of a health care system, which are quite concerning, I'm sure to all of you. Just briefly thinking, I heard nurses laughing about me through the door of the exam room. Doctors have treated me like a specimen after finding out that I'm trans, which makes me feel really dehumanized. I was consistently misnamed and misgendered throughout my hospital stay. I passed a kidney stone during the visit. On the standard 1 to 10 pain scale, that's somewhere around a 9, but not having my identity respected, that hurt far more. I will also put a plug here for open note policy. It's extremely important to use affirming names and pronouns and terminology, not only in person, but also in documentation. And the last quote here, I often do not seek medical attention when it is needed, because I'm afraid of what harassment or discrimination I may experience in a hospital or clinic. All very jarring experiences that are very commonly reported in my research as well. Slide. So thinking about our interviews, if we want to listen and use the language your patient uses for themselves and for their body parts, asking when appropriate, pronouns, description of gender, only asking what sex someone was assigned at birth, if it's relevant to what you're doing, not asking intrusive questions that are not relevant to what you're doing, or about body parts or surgery, gender-affirming care, prior names, things like that. Anything that's not relevant should not be asked. And then, of course, ensuring that you document in an affirming manner, as I said before. Slide. So here, again, we will go briefly over certain aspects of gender-affirming medical care, which encompasses many aspects of treatment. Slide. So first, we'll go through estrogen-based gender-affirming hormone therapy. I prefer estrogen-based or testosterone-based, describing what it is rather than using the adjectives feminizing or masculinizing, which are much more subjective and societally-based, culturally-based, and not as, again, descriptive of what we're describing. So when thinking about doing estrogen- based gender-affirming hormone therapy, there are two components usually, estrogen and then an anti-androgen. Which estrogen specifically? Usually estradiol, E2, which is the most potent of the three physiologic estrogens. We have oral or sublingual, transdermal, or gel, and then, of course, injections as well. And then for anti-androgens, there can be spironolactone, ciproterone acetate, or GnRH agonists, which can be injected. Of course, notably, you want to think about the other side effects of the medications you're prescribing. For example, spironolactone is a potassium-sparing diuretic, so that will, of course, increase frequency urination, might change labs. You want to be thinking about your holistic prescribing regimen. Slide. Then we have here thinking about what will happen when. So here are the changes that one might expect on a certain timeline that one might expect. Again, it depends entirely on the individual. Starting estrogen- based gender-affirming hormone therapy. So things that you might see first within one to three months would be decreased sexual desire or spontaneous erections. Then next, perhaps, changes to the skin, redistribution of fat and muscle, breast growth, testicular volume dropping, decreased terminal hair growth, then later. And then scalp hair may increase, may not. Voice changes generally are not expected in this case. And sperm production research is absolutely horrifically non-existent. So hopefully, our literature will speak more to that in future years. And then, of course, the maximal effects are oftentimes years down the road. Slide. So then monitoring. As I alluded to before, you want to evaluate more frequently at first and then spacing it out later. You want to evaluate for the serum testosterone level. You want to evaluate for the serum estradiol level. And then on a spironolactone, you want to, of course, do the appropriate monitoring for that medication, electrolytes, potassium, kidney function, creatinine. And then primary care screening, which we'll discuss later. And then, of course, don't forget to run drug-drug interactions with other medications, particularly for estrogen, estradiol, because that can influence both the CYP450 system as well as protein levels, which can change the actual and the effective doses of various medications, particularly within psychiatry. Slide. So then we can go to some gender-affirming surgeries, which I will put here for assigned male-at-birth individuals. Of course, intersex individuals might want any of these or any of the other ones we'll go over later. But this is just general guidelines. So facial gender-affirming surgery, electrolysis, hair removal, breast augmentation, or chest top surgery, genital gender-affirming surgery, and then vocal gender-affirming surgery. We'll go through these briefly. Slide. So here, if we think about, we have here on the, towards, I'm not sure if my cursor's visible. If it is, on the bottom of the slide here, we have a couple of facial gender-affirming surgery procedures. We have, there can be mandibular reduction and then tracheal shave, which are common facial gender-affirming procedures. Then we have some images from up-to-date, which again, just examples of if you're interested in this and if you have a patient who's going through this and they want to discuss it with you, there's easy ways to find more information. But certain aspects of the body can be dissected and then rearranged in certain ways. So this here you see on to the left top of the screen, that's testicular removal or orchiectomy. Then there's dissection through fascia. And then this is vaginoplasty result after reduction of the penis. And then there's a new urethra generated and then end result. Again, these are images from up-to-date. So there's numerous types of procedures. And again, we don't have the time here. Slide. So then we're going, jumping to testosterone or T-based gender-affirming hormone therapy. If a patient likes you, they might joke about vitamin T with you, but that would be much more lay lexicon. So then most commonly is parenteral dosing, which is injections of various durations, weekly, biweekly, or then some that are much longer acting. And there's also transdermal gel, which can be very effective for some people, especially if they are allergic to sesame oil carriers or they are afraid of needles or various other reasons. It also has a better physiologic arc of the testosterone metabolism and levels that would be more similarly mimicking that which would be expected in a cisgender man's body. However, there's pros and cons there. And some people can't adequately achieve a therapeutic level with gel. Depends on the person. And then creams, which if someone is not able to take an injection and then is not able to get a therapeutic level with gel, creams can be a great option because compound pharmacies can make them more concentrated. And then there are these also testopel implants, which are done in a brief office procedure every three to four months, and then slowly release the testosterone in that time. Slide. Again, what we went over earlier, what are we expecting for timeline? Are we going to wake up an entirely new person overnight? No. So skin oiliness comes first, along with maybe some fat distribution beginning, cessation of menses, extremely variable. Enlargement, vaginal atrophy, and then deepening of the voice can happen quite early. And then facial and body hair growth take a lot longer. Different hair follicle lifespans are different in how they only reprogram during certain aspects. So it takes many, many years usually to get a full beard, for example, if that's someone's skull, and it also requires the right genetics. And then muscle mass as well increases over time. And many of these side effects will increase, again, on the scale of years and continue to progress. Slide. Monitoring on testosterone, gender affirming hormone therapy is first, again, multiple times the first year, and then you space it out for the serum testosterone level. And then you want to also measure hematocrit or hemoglobin concentrations at baseline and then with dose changes because there's a risk of erythrocytosis. And then also, of course, offering the same sexual health care that you would give for anyone. Of note, people who use their front hole or vaginal opening for receptive intercourse of some sort have decreased front hole lubrication usually, and that can increase micro tearing and risks of contracting HIV. So those definitely want to, and also discomfort. So estrogen cream, E2 cream, can be helpful for comfort, but then also you want to counsel appropriately for SGI testing, PrEP also, and menses, testosterone is not birth control. So that should be counseled appropriately for patients. Slide. So then again, more gender affirming surgeries, we're doing a whirlwind tour here, but it's important to be familiar with names, concepts, and then you can look it up more later on your own. There are multiple types of gender affirming chest surgeries, otherwise called top surgery, most common is double mastectomy plus or minus the free nipple grafts, which can be placed or not. And then periareolar or keyhole, which is a kind of modified or more for smaller chests initially, removing tissue kind of in a donut around the nipple and areola. And then a radical reduction would leave more breast tissue at the end. Hysterectomy can be done with or without ophorectomy. Total hysterectomy means removal of the cervix, which then you don't need pap smears. Other gender affirming surgeries, also in bottom or lower surgeries, include vaginectomy, phalloplasty, which of note oftentimes requires permanent donor site hair removal. So that's important for thinking about for timing and counseling and just preoperative concerns and insurance. Metoidioplasty, which does not involve the skin graft the way the phalloplasty does, it works with the natal phallus or the enlarged clitoris, which are on the same development as, you know, I'm sure everyone remembers from embryology. So the natal phallus can then be kind of freed more from the surrounding tissues for metoidioplasty and then scrotoplasty. And these are not the, this is a choice menu, you know, folks can do, can have phalloplasty without vaginectomy or phalloplasty without scrotoplasty or both or with everything. And then facial gender affirming surgery is less common for those assigned female at birth because testosterone enacts certain changes to the facial structure but also can be done. Slide. So here on the left top is periareolar and then on the top right is the double incision mastectomy for just giving examples of what it would look like pre-op and then post-op on two different skin tones. And then here are other photos from up to date, which show aspects of a radial forearm flap phalloplasty so this is in the OR and then there's a split thickness graft that covers the donor site, taken from the thigh, and then final product though I'm not sure if that phallus is actually made from a radial forearm flap phalloplasty or whether it's anterior lateral thigh, it looks based on the scar like anterior lateral thigh so it may have been mislabeled. Slide. So now we're thinking about primary care. So, you screen the organs that exist, is the basic simple aspect of it, you want to do lipid screening annually if you're on gender affirming hormone therapy, and also for osteoporosis. So basically, if your screening threshold is lower than it would be for cisgender populations, but it depends on gonads, it depends on hormone therapy over life, and then, yeah, go from there but again you can look this up for individual patients but it's good to be on your radar. Slide. So now we're thinking about menstrual suppression and cessation which is an extremely important aspect of gender affirming medical care but oftentimes ignored. This can be extremely important for reducing dysphoria, and can also, at least through my research, results that aren't published now, commonly is helpful for helping with eating disorder symptoms as well, which is really important to think about. So one could use IUDs, progesterone or copper IUDs, though copper IUDs can oftentimes increase dysphoria, so that would be why you're using progesterone here, both for menstrual suppression, as that can often lead to amenorrhea or infrequent menses. Nexplanon implants are progesterone as well, oral contraceptives without placebo breaks, or a hysterectomy with or without ophorectomy. Slide. Fertility research really stinks. Basically, it's important to talk about fertility before starting gender affirming hormone therapy. This is most important for estrogen based hormone therapy. It appears based on the limited research that exists that testosterone based hormone therapy does not particularly change quality or quantity of eggs for future egg retrieval or pregnancy chances, and eggs can be retrieved transvaginally or trans abdominally, which is really exciting for those who've already undergone vaginectomy. And then folks who have all sexes and genders and gender experiences can induce lactation for breast or chest feeding with medication, which is cool. And there's some studies in the literature about that. Slide. So now psychiatric care. This is all pretty straightforward, you want to meet people's basic needs because they can't, you will never cure depression in someone who's depressed because they don't have housing, that's pretty intuitive right that SSRI isn't going to get there. And then resilience and support systems and then resources for gender affirmation which I said before, as desired, including social and legal affirmation and then gender affirming psychotherapy with a trans non binary intergenerational expansive competent provider. And then psychopharmacology, which is, we can go over very briefly next and support groups can also be helpful. Slide. So thinking about medications. I don't need to teach everyone here how to be a psychiatrist, that's where we're all coming from but I thought it was important to note that drug drug interactions are extremely important as I alluded to with estrogen earlier so it's important to run possible drug drug interactions when starting any new medications so carbamazepine for example, induces sit three a four which metabolizes estradiol so that it interacts in one way and limotrigine can decrease serum concentrations of progestins but then estrogen can decrease serum concentrations of limotrigine spironolactone of course can increase lithium concentrations through its work in the kidney and lupron generate agonist can cause qt prolongation and all second gen antipsychotics can cause hyperlipidemia, which is also a risk factor with gender affirming hormone therapy. So these are things that we should be thinking about as we're making all of our psychopharm decisions slide. So I have references, happy to send you some of these via email later or if I don't know if these will be shared later, but we can keep clicking forward. I have more references on the next slide. After this I also have some resources here. My general advice, if you're looking for resources is to read content by and consume content by trans non binary and or gender expansive creators plug for a textbook forthcoming from the APA press gender affirming psychiatric care, which covers a lot of this in depth. And that's the end of my talk. Pass it on to Dr. Erickson drop. Thanks so much, Teddy I'm really glad to be here. I didn't know that they're going to be such great introductions in the beginning but these are all the things that I was going to say about myself and who I am. You already know all this. We can go to the next slide. So, I wanted, I'm going to be just talking for a very brief period. And I'm going to be talking a bit about first LG LGBTQ people in general and then trans identities within the DSM and the history. So, starting off with sort of queer identities, gay, lesbian, bisexual identities, they actually appeared before trans identities in the DSM in the DSM one. In the DSM one homosexuality was considered a sociopathic personality disturbance continued in the DSM two, and that was then considered a sexual deviance and on until we started to see some research studies and real advocacy from gay communities, and from researchers and from within the APA psychiatrists that were pushing for deep pathologization of gay and lesbian identities. So, in the 60s and in sorry in the 50s and in the 60s we saw some really interesting research coming out. One person who was really important in the history of deep apologizing homosexuality was a psychologist named Evelyn hooker, and she did a study that she published in 1957, where she looked at two groups of men, one group that identified as gay and the other group that identified as straight, and it was sort of common knowledge in the mainstream at that time that gay people were like more likely to have mental health issues than straight people but her study actually showed that the gay men in her study were more likely to have more signs of mental illness than the straight men in her study and this really hit the field, because a lot of people sort of didn't understand or didn't know that being gay in itself was not a mental illness. And this was projected forward into the civil rights movements of the 60s and the early 70s, and you had, you know, people from within the APA as well as advocates working to take homosexuality out of the DSM so you'll see in this picture on the bottom Barbara Giddings and Frank Frank Kameny are two advocates who worked very hard on gay issues during this time and then on the right is a psychiatrist who went by Dr anonymous and spoke at the 1972 APA meeting. He didn't come as himself he came as Nixon in an oversized suit and with a wig on and he actually used a voice changing machine to make sure that no one could recognize him because he had been. And then there was a gay psychiatrist who was fired from his job. And then by a vote of the APA in 1973 homosexuality was removed from the DSM. So we can go on to the next slide. Great. So just a brief history of trans identity in the DSM so again there there wasn't any mention of trans identities in the DSM one when there was about homosexuality at that time in the DSM to there's a mention of a, a mental illness, called transvestism. And by the time the DSM three came out. It was being called gender identity disorder and and it could include one called transsexualism. I think a really important to note is that the DSM three really was a paradigm shift in the way that you know the writers looked at mental illness, they were looking at it in a very different way and to use research, you know, to push forward diagnoses with an evidence base. Unfortunately, at the time, this diagnosis really carried over without the kind of rigorous study that a lot of other diagnoses had at the time. So, it was carried on again into the DSM for as gender identity disorder and then into the DSM five where there was quite a bit of conversation. And it was labeled in the DSM five gender dysphoria. The real differences between gender identity disorder and gender dysphoria had to do with the definition of gender dysphoria, meaning that someone who had a trans identity but didn't have specifically this feeling of dysphoria wouldn't meet criteria, of course, people who fall in a category of identifying as trans do experience some sort of gender dysphoria and that's related, you know, we think, in many ways to societal influences and the way people are treated it's hard to not have dysphoria when your identity is pathologized throughout sort of mainstream society. And then the other difference was you could sort of graduate from having a mental health diagnosis. If you had, you know, medical interventions and no longer felt, you know, gender dysphoria about your body, which is also a really interesting concept that you could have a mental illness that could be cured, not through, you know, therapy or psychiatric medications but through medical interventions. And so, go ahead and go on to the next slide, thanks. So I wanted to compare this to what's been happening with the ICD over the years. So the ICD, actually the most recent ICD, which is ICD-11, we use ICD-10 still within the United States because we're always, you know, years behind, but the ICD-11 has removed any sort of trans related or gender related diagnoses from behavioral, from the behavioral parts of the ICD and has moved them into another category. This slide is a little bit old so it says proposed but this is where, this is where those diagnoses were moved. So it's no longer considered, trans identities are no longer considered, you know, mental illnesses within the ICD. We can go down to the next slide. So I think this is my last slide I just wanted to talk a little bit about moving away from an illness framework of trans identity, and the idea that it I think is an important move for the APA to move away from pathologizing trans identities within the This can create a lot of distance between communities and providers. If people feel like a, you know, a whole group of providers, psychiatrists is pathologizing them for just existing. We know from research that there's nothing inherent about trans identity that fits the definition of a mental illness. It's, you know, mental health issues that go along with trans identity are related to societal stigma and discrimination and harassment It's also no longer useful to have trans identities as part of as listed as mental illnesses within the DSM really mental health clinicians no longer use these diagnoses with any kind of frequency. When they're seeing patients, they're typically giving them diagnoses that fit with the experiences they're having such as anxiety, depression, PTSD, that kind of thing. And researchers almost exclusively use trans identity in research studies rather than, you know, any sort of diagnosis of gender dysphoria. When I've when I've looked, certainly in PubMed and other sources. It's really hard to find any researchers that are using, you know, DSM diagnoses to conduct research and then you know surgical providers will bill with ICD or CPT codes. So they don't use, you know, DSM codes either insurance companies, sometimes require this diagnosis in order to sort of approve someone for surgeries, but that could easily be changed. And they could easily use ICD codes instead. So I believe that's the end of my slides. Yes. Thank you. Yes, I am just going to share slides myself because I have a couple extra that I added so give me a second. I do I'm trying to see if this works. Can you all see the slides. I can see it in your speaker mode now. Okay, so let me stop and see if I can do it. Okay, give me one second I'll try it again. Okay, this is better. Yes, we don't see it as like as like full screen we see it as if it's like if you click slideshow and then play slideshow from beginning. Yes. Are you seeing it full screen because oh no now it's still in presenter mode. Well, up to you what you want to do. I'm trying to see a small presenter view and slides. Oh, but then it still doesn't let me do it. Okay. Well, yeah, I'm trying to see if there's another way to do this, I guess that's okay we'll just see. Actually, let me see if I can do it. Give me one second. Yeah, thank you. Yeah, you guys. Yes, perfect. Okay. So I'll just tell you when to advance. So thank you all for joining us for this. Yeah, my presentation is the last one. We're just going to go over some sort of controversies that are current, and just as a way to kind of frame the discussion and tell you sort of what we're trying to, why we're doing this, you know, because part of this is that there's a lot going on right now with transgender and non-binary and gender nonconforming patients and their mental health rights. And so, and a lot of things that affect their mental health. So that's, that's sort of the overarching, you know, urgency with which we give this presentation. So next slide. Next slide. Yeah. So one of the, these kind of controversies has been something that was brought up to us in the council of minority mental health was autogynephilia, which is in the DSM. It's a term coined and used by Ray Blanchard in the eighties and nineties. It was used as a specifier in transvestite fetishism, which was an old diagnosis, but also mentioned in the chapter and, and, you know, sort of something that we're trying to change and also was mentioned in the chapter on gender dysphoria as an outdated term. The reason I bring it up is just sort of to put it on your radar, because it is something that is used by transphobic people who are trying to characterize some people who are assigned male at birth who transitioned to female as sexual deviants who only want to transition out of sexual gratification. So if you do see that used, or, or, you know, just so you understand the context of it, the WPATH has questioned the inclusion of the term and advocated for it to be taken out of the DSM totally. So, you know, it's certainly in the, in the DSM-5 revision, it has been taken out of, I think it's been taken out of gender dysphoria, but not the transvestite area. So we're still working on that, but that's sort of something to put on your radar. We wanted to bring that up because we had people approach us about that. Next slide. So current controversies that are going on. So, I mean, one of the big ones is conversion therapy, you know, and, you know, we think of conversion therapy in terms of changing sexual orientation, but also there have been efforts to change or, or try to, you know, sort of, I guess, you know, change gender identity as well. And, and that has happened, you know, throughout the last few decades. Now there's statistics say 13% of transgender adults have been the victim of conversion therapy and, you know, laws that prohibit licensed mental health practitioners from subjecting minors to this conversion therapy are in several states. But only 48% of LGBTQ people in the U.S. live in a place with these anti-conversion laws. So obviously there's more work to be done. You know, we can ban it with minors, but, you know, for adults, it's a little bit harder because they are, they can willfully agree to do this. And also for non-licensed practitioners, we don't have the capacity to change that because they, you know, there's no licensing body that can govern those people. So we're talking about in other settings than a mental health care setting. It can be difficult. But, you know, it's something that obviously we discourage and we know the mental health outcomes are bad in these scenarios. Next slide. And one thing that has gotten a lot of attention lately is participation in sports. You know, we had in the Council of Minority Mental Health, you know, I had written statements about this for the, you know, to advance through the APA. We do already have a policy as part of the APA position statement. The APA does that, you know, transgender people and gender non-conforming people should be able to participate in and then be included in public spaces and public participation like in sports with, you know, with their identified, you know, gender and not the gender that they were, you know, their gender assigned at birth, but their, you know, gender identity. And so that is kind of something that we're still working on and, you know, in the country because there's a lot of backlash. So this has been, you know, a complicated issue. 18 states have passed legislation banning transgender students from competing on girls and women's teams. And obviously that's where most of the focus is, is with women's sports. And a majority of states, unfortunately, introduced bills in 2022 and 2023 that would bar transgender students or gender non-conforming students from girls and women's sports. So that's something that we still work on and we're trying to educate people on. Next slide. And the last thing I wanted to say was treatment of transgender and non-binary minors. You know, because there's a lot of states, unfortunately, now that are trying to ban this procedure, Arkansas, Alabama, Oklahoma, and Florida have already banned it. In Tennessee, there's an injunction against the law, which was already passed and Utah just passed the ban in 2023. I just got an alert earlier today that Montana, you know, it went out of committee in the Senate, another bill that would ban this as well. So again, something to consider when you know the statistics that Dr. Fonseca and others have gone over, it is a salient issue. Next slide. And that was it. Yeah. So basically for the CMU questions, you know, we unfortunately were going to do a poll. We couldn't do it. So we will, you know, just have to have you sort of answer those on your own. And we wanted to open this up for the question and answer session for the last 15 minutes. So I'll have all the panelists come back. And we got a few questions through that chat. And I don't know if there'll be more, which you can please ask, you know, as we go along. So I will sort of start with, you know, from the top and sort of go through as many questions as we can. If we don't get to your question, obviously, please, you know, follow up with us and follow up with APA. And we'll be happy to answer as many questions, you know, outside of this as we can. So the first person, oh, and there you go. We actually did get some of those polls working. Yeah. And essentially, yeah, you did get all the right answers. So yeah, the most common answers. So I'll just, yeah. So you guys did a good job. We don't have time to necessarily go through those, but let me ask the questions that you all want to know. So the first one from Kelsey is when working with patients that want to start HRT, the WPATH requires mental health to be relatively well controlled, but by the standards of care, how do you draw the line of not gatekeeping, but keeping patients safe and making sure they're stable prior to adding something new to the mix? So does any of the panelists want to take that question on? I'm happy to start. And then if anybody wants to jump in, yeah. I mean, I think there are relatively few contraindications to starting hormone therapy. And I think it's really important to note also, if you're working in an emergency or an inpatient setting and someone comes in and has been on hormone therapy in the past, it's really important to continue them on their hormone therapy, even if they're in the middle of a psychotic episode or a manic episode, as long as it's being prescribed by someone at a sort of normal therapeutic dose. There are very few instances in which someone is taking way more than they should be taking. Typically people are taking exactly what's prescribed by their providers. So if you're the person, which you probably wouldn't be if you were the psychiatrist, but if you're the person who's starting hormone therapy, rather than just continuing it as they come the hospital, that primary care provider would just make sure that there are no red flags. So you don't want to start someone on hormone therapy if they're in the middle of experiencing a manic or psychotic episode. But pretty much most other sort of mental health conditions, you can start someone on hormone therapy while they're experiencing, for example, depression, anxiety, almost any other mental health condition. So I think it's just important to note that if someone's already on hormones, to continue them on them unless there's some really important red flag. And the only reason you wouldn't start someone on hormones at the time is if they're experiencing an acute manic or psychotic episode. And then just to add to that, the one other contraindication would also be starting someone who is actively pregnant on testosterone if they want to kind of keep that pregnancy and carry it to term, because it can be too autogenic. In terms of surgical interventions, our role isn't, again, to gate keep. And again, that isn't necessarily something that psychiatry does, but it could be something that social work does or something that psychology does. And it's more looking at, does this person have someone who can help them in case they need help post-surgery, like with surgical recovery, help them with ADLs and things like that? Are they able to kind of stay close enough to the facility that's carrying out the surgery so that they can come in for follow-up? What kinds of problems have they had in the past in terms of medical follow-up and how can we help optimize their access to that? See if they have transportation issues, stuff like that. So that would be more kind of what we're looking at for pre-surgical. Yes. And then just kind of like any surgical, general surgical contraindications, as you would for any other surgery involving general anesthesia or things like that. Absolutely. And with that, I think it's really, it's sometimes most helpful to put into context of the only other surgical procedures for which there is usually a prior psychiatric evaluation of some sort would be for organ transplantation or bariatric surgery. And the evaluations in those cases certainly are quite different than the standards of care version seven. And I guess standards of care version eight is a little bit less gatekeeping, but it's very interesting if the other reasons for doing a pre-surgical evaluation would be exactly what Dr. Fransico was saying, you know, readiness, understanding of the procedure, readiness for the after surgery care, social supports. And that's really what this evaluation would be too, not at all about, do I believe that you are your gender? Like that's not what our job is to evaluate. Our job as someone's doctor is to say, how can we help you make sure that you're safe getting the care that you need? I think most of us have heard of the Applebaum criteria for capacity evaluations. And that's, I think probably what all of us in this Zoom room use to evaluate clients for, for surgeries. As Teddy said, we're not judging whether some, whether we believe someone, you know, fits a certain gender category, we're judging whether they have capacity to make decisions for themselves about having surgery. Yeah. Thank you everyone. Yeah. And I'm trying to sort of group these questions into, you know, so we can answer as many as possible. What I, I mean, I guess one thing that has come up a couple of times is, yeah. So any suggestions from Albina, this question, any suggestions on how to deal with colleagues who believe that youth who identify as trans non-binary should not receive treatment because it could be a phase, you know, and colleagues who believe in this idea that youth are presenting more often because of contagion, you know, is what they're asking. So any advice on how to deal with that and how to sort of navigate that with colleagues or others? I can start off again if other people want to add. So I, you know, I think when, when you're talking about young people, it brings up a lot of feelings for a lot of people. And I think it's important to remember that for young people, most of the interventions are social, you know? And so I think that, you know, people sort of like read headlines and think that, you know, children are being prescribed medications or having surgeries, and that's just not true. And so, you know, when we're talking about children or young teens transitioning, this is typically social transition where the young person would, you know, be able to use the pronouns that they want to use in school, the name that they want to use in school, the, you know, sort of like social environment that they're in, sort of adapting to, you know, who they are. And then there are, there is real evaluation. I think a lot of people worry that there isn't, but there is real evaluation. There are people who are well-trained to meet with young people and their families as they're getting to the point where they're thinking about any kind of medical interventions like, you know, puberty blockers, for instance. And puberty blockers have been around for quite a long time. We've used them for precocious puberty for, you know, many decades, and we know that they're safe and effective. And they can actually provide young people and their families some time to really think through their later decisions. So I think that there's a lot of sort of, I don't know, hype about this issue, but actually, you know, when we think about it, most of the interventions are simple and very reversible and social interventions. And, you know, we have very qualified medical centers where people with a lot of experience work with families and young people to decide on, you know, any sort of medical steps. And with that, puberty blockers are also reversible. If you stop them, puberty then proceeds. So I think that that's an important thing is that nothing irreversible happens until generally mid-teen years at the very earliest, if someone's been well-connected to care for a while. Also, one could think about, oh, what if a child changes their name and they decide they want to change it again to something new or what they had before? How many children change their nicknames during childhood at some point or other? Maybe they spell their last, their nickname with an I, and then they change it to a Y. That happens. And people learn, everyone adjusts. So there's a lot of overblown anxiety about this, which is fixating on things that aren't real in order to avoid the discomfort with actually children having genders that are not what are assigned to them. And I also wanted to add, particularly with children, gender exploration can be very, very much a part of the normative developmental process. And so what if someone decides tomorrow that that isn't the gender that they identify with? I think a lot of this comes down to our understanding of gender at large and that it is very much a social construct. It isn't rigid, it isn't black and white, it isn't binary, and that gender can evolve over someone's lifetime too. So I think kind of taking a step back about how we understand gender in general will help us approach this question a bit better too. I think it's also notable that if we're thinking about regret for receiving gender affirming care, which is of course what many of these articles are very anxious about, regret rate for gender affirming surgery is 0.1 to 1% depending on where you're looking. The regret rate for having children is about half. The regret rate for having a knee replacement. There's so many things that are not controversial and are extremely prevalent, and then this is 0.1 to 1%. Again, it's not zero, but also I think we can examine as a society why we're so worried about that possible 0.1% more so than the 44% of trans individuals who might attempt suicide in their lifetimes, and that's a very different number. I would say that most people that, you know, research shows us that most people who regret having surgeries, it's not because they don't identify as trans. It's because of, you know, sort of the outcome of that particular surgery, maybe losing sexual function or having some sort of aesthetics or disfigurement that they're concerned about, but it doesn't typically have to do with their actual gender identity. Yeah, I think a lot of this also comes from a very cisgender concern where you don't really see the person as trans and assume that they're actually cisgender, and you think, well, if I am cisgender, and this is the body I have, and I want to be very much a woman or a man, and I woke up tomorrow, and I was in the wrong body, I would be really, really, really uncomfortable, and this would be really traumatic for me, when the reality is that is what most days are like for folks who are seeking this care, and you are depriving them exactly, you know, that opportunity to be who they are by coming in and saying, what if you regret that? Yes, well, thank you. I know we're almost out of time, and I mean, there were a lot of questions, so I feel, you know, so I'm sorry for people that we could not get to your questions. I would say a lot of the issues, you know, that the remaining questions that we did not get to, a lot of them are based on where can we get more information, you know, where can we, like as psychiatrists, learn how to prescribe hormone therapy, you know, is there an option for that? How do we advocate for our patients? So just as final thoughts, anyone have any, you know, suggestions for where to look for future directions in this? One is AGLP, which Amir mentioned earlier, which is the Association of LGBTQ Psychiatrists, has an online curriculum that was designed for psychiatry residents to learn more about LGBTQ identities. And that's on the AGLP website, and it's for free for anyone to access. And I would also direct everyone towards WPATH, the World Professional Association for Trans Healthcare, because they have tons of resources, and you'd be able to learn quite a bit there. And I would kind of push and argue a little bit that so long as gender dysphoria remains in the DSM, it is a psychiatric diagnosis. So with the adequate training, it's not out of the realms for us to be able to continue prescribing hormones in particularly, but even potentially initiate hormones in some patients. Exactly why we talked about that today. I also would direct people towards Trans Bodies, Trans Cells. The second edition is gorgeous. You also see a photo cameo for me from my, you know, not doctor life of photography, but it's a wonderful resource. And again, thinking about the voice, like it's, you know, thinking about things that are written by and for community are really important. Speaking briefly to one of the questions, which is about neurodiversity, just briefly, there is an increased prevalence of transgender, non-binary, inter-gender expansive identities among neurodivergent communities, for example, autistic or ADHD folks. And there's a great book called Trans and Autistic by Noah Adams and Bridget something. But if you search Noah Adams, that's great. There's also a, there's an article, a systematic review I had published last year or earlier this year with Noah Adams about ADHD and gender identity. So that's, if you want more information about that overlap and what we know and what we don't, I would look at those places for the, it was an anonymous person who put that in, but hopefully that answers your question. Yes. And I would also like to just plug the, you know, at the APA annual conference, which is, will be in San Francisco in May. We definitely have a lot and AGLP has, has tried and also other others are working to include more sessions in there. So hopefully there will be a sessions related to what we talked about tonight, as well as other LGBTQ mental health topics. So, and there's actually a lot of them this year, so that'll be good. So hopefully, you know, we can all learn more from that. Yeah. But any other final thoughts from our panelists? I just want to say that I'm so glad that everyone is here and has been open to thinking about this with us and open to learning more and having these conversations, because sometimes especially for folks who maybe are uncomfortable with, with the subject it can be quite difficult to sit through this. And I appreciate you sticking through and being eager to learn more. Yeah. So thank you to everyone who came to this. Thank you for everybody who is here. And again, it is recorded, so we will be able to watch it again. If there's any questions about resources, hopefully some of these things that we've linked to, or put in the chat, you can look into further. Like I said, we're always available to answer more questions and you could reach us through the APA. And we're most of us are all members, we're all active in it. So I think otherwise we will sign off for this evening. And like I said, we're hoping that this is the first of several of these fireside chats that are related to LGBTQ mental health. So hopefully any questions that you did have or any future sessions that we could do or should do, please let us know, because that will help us build the next, the next few. And the conversation is not over. So thank you all for joining us. And thank you to the APA staff that helped us put this together and run this tonight. And yeah, we'll be, we'll see you all at the conference.

LGBTQ+ mental health

transgender

gender nonconforming

psychiatric care

healthcare providers

gender-affirming care

hormone therapy

gender affirmation

psychopharmacology

conversion therapy

APA conference