Welcome, everyone. This session is Transgender Affirming Care, What Every Psychiatrist Should Know. This is session 1142. I'm honored to introduce you to my esteemed colleagues. Dr. Neetha Bhatt is Associate Director of Medical Student Education at Wright State Department of Psychiatry. She's an attending physician at Twin Valley Behavioral Healthcare in Columbus, Ohio. Dr. Mira Menon is a psychiatrist at the Ohio State University Counseling and Consultation Service and serves as chair of the APA College Mental Health Caucus. Dr. Jessica Porcelain is a fourth-year resident at Wright State University Training Program and is the recruitment chief. Dr. Oakland Walters uses he, him pronouns and is currently completing his final year in psychiatry residency at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire. And I am Julie Gentile, professor and chair of the Department of Psychiatry at Wright State University. None of the presenters have conflicts of interest or relationships with pharmaceutical companies. There was no funding for the creation or presentation of this material. Dr. Porcelain is a member of the Department of Defense and the United States Air Force. The views shared in this presentation are those of the presenters and are not reflective of the policies or the views of the United States Air Force. These are our objectives for this session. Identify the neuroanatomical variations in transgender people. Review transgender issues in individuals with autism spectrum disorder. Enable adaptations for clinical settings to be inclusive of transgender patients. Identifying appropriate mental health treatment that is sensitive to transgender people. Current practice models, the difference between gatekeeper and informed consent. Integrate prevalence of mental health and general medical issues in transgender people. WPATH standard of care and letter writing 101. It's important for mental health professionals to recognize, understand, and be comfortable with topics related to gender diversity. Current research reflects that the number of people who identify as transgender is greater than what was previously known. Despite this, mental health resources in our communities have not expanded in a way that reflects a commitment to transaffirming care. In addition to limitations in resources, transgender individuals may have difficulty accessing healthcare due to fear of stigma and discrimination, even within healthcare agencies. Research continues to reflect that many transgender individuals live on the margins of society, facing stigma, discrimination, violence, and of course, poor health conditions. So is gender diversity a mental disorder? According to the World Health Organization, Western society has classified people with gender diversity as disorder. This just sustains and aggravates stigma and associated challenges that individuals face. So back in 2018, the WHO included gender incongruence under that umbrella of sexual health, as opposed to the list of mental disorders. We expect that in 2022, the ICD-11 will be released, and this previous codified categorization system will be slowly replaced. The messaging from national and international organizations can worsen stigma, can decrease public awareness, and certainly can limit access to care. Changes and updates need to be made in a timely manner to address these issues. There are many geographic areas in the world, for example, the Caribbean, much of Africa, and much of the Middle East, where there is little or no information available regarding gender diversity, their lived experiences, or their healthcare needs. Across much of the world, individuals with gender diversity experience stigma every day. They may be viewed as morally corrupt or as having mental disorders. They often experience minority stress, which often leads to poor health outcomes, discrimination, and victimization. Adolescents with gender diversity often leave home early or are forced to leave home. Unemployment or underemployment often leads to exposure to unsafe sex practices and increase in risk of substance use disorders. HIV prevalence, for example, in transgender populations worldwide is 49 times greater than the general population. 35% of individuals between ages of 5 and 18 who revealed gender diversity were victims of physical violence, and 14% were victims of sexual violence. Suicide is another significant concern. Suicide attempts range from 1 to 6% in the general population. In contrast, suicide attempts are reported in over 40% of individuals with gender diversity. The World Health Organization funded and published the stigma slope shown here. When individuals with certain diagnoses are stigmatized, they experience worsened outcomes and may have decreased expected life. In addition to gender diversity, race and ethnicity are additional sources of stigma. Gender diverse populations of color experience the most severe discrimination, poverty, and lack of access. If they find care, it's common for providers to lack skills in this area. The discrimination in medical settings often mirrors broader society. Gender diverse people often make use of parallel providers who often come from the transgender community. Parallel providers are often medically unqualified and may use substandard equipment and materials. They engage in self-administered and unmonitored hormone treatment. Sometimes these activities are part of social gatherings. Structural and functional MRIs in this space have been surging over the last decade to identify biological markers associated with gender diversity. Low sample sizes are an issue, and most studies had larger cisgender control groups versus the actual subject groups. Most larger studies showed that the corpus callosum anatomy did not change with hormonal treatment but was more consistent with gender identity. There's a decrease in the size of the hypothalamus in trans women status post-hormone treatment. In contrast, there was an increase in the hypothalamic volume for men. This could be interpreted as a sign of plasticity or sensitivity of a hormone-treated hypothalamus. Regarding functional neuroanatomy in transgender men, testosterone treatment can deepen the voice to approach the male vocal pitch. In transgender women, estrogens do not have the same effect, and so at times vocal surgery and or speech therapy may be helpful. Patients with gender diversity experience a high rate of depression and anxiety and are unusually high risk of suicidality and non-suicidal self-injury. Minozygotic twins had significantly higher likelihood of concordance for transition versus dizygotic twins. In one study, male minozygotic twin pairs were 33% concordance for transition to live as women, including two pairs of twins who were reared apart. In contrast, concordance for transition among female minozygotic twins was 23%, where one twin had transitioned to live as a man and included a pair of twins who were raised apart. Concordance among dizygotic twins was very low by contrast. As more literature is published in this area, it appears that there's a correlation between gender diversity and some traits of autism spectrum disorder. The traits that occur most frequently are lower levels of empathy, an element of rigidity with routines, and diminished theory of mind. Theory of mind usually develops between ages four and eight years and is the ability of the child's developing mind to interpret and understand the emotional state of another child. Although the prevalence of anxiety and depression is higher in persons with gender diversity, those who pursue gender affirming surgery or hormonal treatment have fewer mental health symptoms and are more comfortable with their bodies. Unfortunately, the prevalence of suicide attempts does not decrease with surgery or hormonal treatment. Screening for suicidality should be carefully conducted. Open conversations about mental health symptoms must be prioritized. The history of individuals with intellectual disability and those with gender diversity have several important intersections. The correlation between gender diversity and intellectual disability is even higher in children with gender diversity. Overall, about 20% of individuals with gender diversity reported some clinical features of autism spectrum disorder. In transgender adolescents, it's almost twice as common for parents to report gender diversity in their children versus the adolescents self-report. Let's take a look at some gender diverse signage. Using a public restroom can be a very stressful experience for a person with gender diversity. Many have been harassed, confronted, stared at, or judged in public restrooms. 59% reported avoiding use of a public restroom. Using signage is a way to safely communicate an accepting environment and should be a priority. If you're treating a patient or if you interface regularly with a person and you do not know their pronouns, you can respectfully ask questions. What pronouns do you use? How would you like me to refer to you? Or how do you like to be addressed? In a medical office setting, these signs send a message of inclusivity. Those are important because they facilitate communication. These are some community resources. It's important to know if there are public spaces, for example, the gender neutral restrooms, for example, the state laws related to driver's licenses, and maybe some national websites. Educating yourself and being aware of local, statewide, and national resources is a sign of respect and strengthens the therapeutic alliance. And here are some key takeaways. Ask don't tell. If you want your patient to be honest, you need to ask them how they identify instead of making an assumption. Ask don't tell. Names and pronouns matter. This is simple but incredibly important. People with gender diversity spend an enormous amount of time battling for recognition. Misgendering can be done deliberately or can be completely accidental. You can make a significant difference as a provider to use a patient's affirmed name and pronouns. It can be the first sign of caring respect. Do your own research. 24% of people with gender diversity who sought medical care reported they had to teach their medical provider about gender diversity in order to receive appropriate care. It's our responsibility to educate ourselves, but asking respectful questions when needed is appropriate. Intersectionality is critical. The transgender community is diverse, expanding, and heterogeneous in every way. It's important to understand that we cannot use a cookie-cutter approach. Let your office speak for you. Look at some trans-affirming signage and consider posting a sign on your office wall. The patients will feel seen and cared for, even if you don't discuss gender identity during that particular visit. And finally, remember it's a team effort. Ensure that everyone on your team is ready to affirm transgender patients. One way to ensure this is to include transgender individuals on your staff. That concludes this portion of the presentation. I would now like to introduce my colleague, Dr. Neeta Bhatt, to present the next topic. So I'm Dr. Neeta Bhatt, and I will be spending some time speaking about transgender or gender diverse terminology and practical adaptations. The letters LGBTQ represent both sexuality and gender. The LG and B address an individual's sexuality, mainly who they're attracted to, while the T refers to a completely different process, an individual's gender identity. The Q has multiple meanings and most commonly is interpreted as queer, which is a catch-all term for the LGBTQ plus community. But it can also mean questioning or still understanding identity. So it's very important to ask a patient who identifies as queer to explain what queer means to them. The plus acknowledges that not everyone fits into these categories of people who identify as members of the LGBTQ plus community. And so the gender unicorn really helps us understand and conceptualize these terms. So the TSER, which is the Trans Student Educational Resources, is a U.S.-based organization that promotes the well-being of transgender youth, was founded back in 2011 by activists Alex Sinello and Eli Ehrlich. And it's the only national organization led by transgender youth themselves. TSER created this gender unicorn back in 2014 to describe the spectrums of gender and sexuality. And it was quickly picked up by schools, colleges, universities across the entire world and has been translated into over a dozen languages. So let's take a look at this gender unicorn. So going into gender identity, gender identity is one's internal self of being male, female, or neither of these. It can be both or another gender, a trans man, a trans woman, or non-binary. So when talking about some of these terms, transgender describes people whose gender identity differs from their sex assigned at birth. When using the term cisgender, this is a person who is not transgender and their gender identity is the same as their sex assigned at birth. Non-binary is not exclusively as an individual that does not exclusively identify as a man or a woman. So moving on to gender expression. So that's really culturally defined. It's the physical manifestation of one's gender through maybe clothing, hairstyle, voice, body shape. And then sex assigned at birth is the assignment and classification of people as male, female, intersex, or another sex based on a combination of anatomy, hormones, and chromosomes. And finally, physically, sexually, and or emotionally attracted to. That's important to note that attraction can come from a variety of factors and is not limited by gender identity, gender expression or presentation, or sex assigned at birth. So this chart is a pronoun chart that was actually taken directly from the APA website. And the APA website has a section that provides resources for providers for gender affirming care. So as Dr. Gentile mentioned, pronouns are very important and should be addressed with patients actually at the start of treatment. So when a clinician is unsure of someone's pronouns, it is very appropriate for a clinician to lead by example. So I might say, hi, I'm Dr. Bott. My pronouns are she, her, and hers. And then I would ask my patient, what are your pronouns? Other good ways to sort of show support is to consider having your pronouns listed on your name tag, maybe on your office sign, those sorts of things. Should a clinician make a mistake in using someone's pronouns? Simply apologize, thank the patient for correcting you, and continue with the conversation. So a list of commonly used pronouns that clinicians should be aware of are listed here. And please note that they, them, and theirs are frequently used and even encouraged to be used as a singular pronoun. So for example, instead of saying, he needs a medication refill, it can be stated they need a medication refill. As you see here, most of these pronouns we understand, they're pretty self-explanatory. There are some others though. So for example, Z, Z, Z, could you please tell Z when Z's appointment is? And so it's important to recognize that some individuals might identify as she and her, but also as Z. So gender dysphoria, let's talk a little bit about gender dysphoria. So not all transgender patients have gender dysphoria. So it's really important to note that. And you might want to consider alternative billing for each specific individual patient. So this isn't a billing code that should auto-populate for every transgender patient. I'd like to talk a little bit about intake forms. But before I get started, I just wanted to take a second to thank one of our colleagues, P.D. Peterson, who previously served as director of Wright State's LGBTQA Affairs for helping to provide some of the information for these intake forms. So when understanding sexual orientation and gender identity, it's important to ask the patient how they view themselves as far as sexual orientation. It's important to ask their current gender identity and their sex assigned at birth. So as we have listed here, to assess sexual orientation, you might ask, do you think of yourself as straight or heterosexual, lesbian, gay, or homosexual, bisexual, something else, I don't know, or I do not wish to disclose. To assess current gender identity, you might ask, are you male, female, transgender male, transgender female, gender queer, an additional gender category that is not specified, or do not wish to disclose. And then finally, to assess sex assigned at birth, ask, were they assigned male, female, or do not wish to disclose. Moving on with intake forms. To aid in patient-centered care with LGBTQ patients, it is recommended that registration forms ask for patient pronouns in two fields for patient name. So one for the name that's indicated on their insurance card or legal documents, and the other is the name that the patient prefers to utilize. This is important for transgender patients, as they may have a name and gender identity that differs from what's indicated on their insurance card. Indicated name and pronouns should also be consistently used by all members of staff, as Dr. Gentile stated. It is important to ask pronouns and use open-ended questions, as indicated here. Some gender queer patients and others who do not identify as male or female may use the gender terms that we described previously. Names and pronouns should be asked during the intake appointment, and again, at least annually, because this can change over time. So when considering intake forms, it's important to use language that does not presume the patient's heterosexuality, and allows the clinician to comfortably and routinely ask about a patient's sexuality, sexual behaviors, and gender identity. So some examples of exclusive language that you want to avoid are, are you married or single, asking a female patient, do you have a husband, asking a male patient, when did you first become interested in girls? So some examples of more inclusive language are, are you in a romantic relationship or dating anyone, are you currently in an intimate relationship? Very important that we do not make assumptions. So do not assume that patients are heterosexual just because they have not said otherwise. Do not assume that LGBTQ patients do not have children. Do not assume that self-identified gay men do not have sex with women, or that lesbians never have sex with men. Do not assume that same-sex erotic feelings are merely a passing phase, and therefore should not be taken seriously. We do want to take those seriously. Avoid conceptualizing gender identity confusion as an immediate need to establish a male or female gender identity. Avoid common stereotypes, and do not assume that domestic violence does not occur within LGBTQ couples. Do not assume relationship sex roles, i.e. that one partner is the top, one is the bottom. We really want to avoid those types of generalizations. So we want to talk a little bit about culture and space, which Dr. Gentile did talk a little bit about, but we want to reiterate them. So when creating an inclusive environment, you really want to consider culture and space. So you want to greet and interact with patients using gender-neutral terms. You want to reaffirm confidentiality, and that's a really big one. You want to show support and explain that everything that we discuss is confidential, as we do with most patients. As Dr. Gentile mentioned, we do want to hire diverse staff, provide an all-gender bathroom in your waiting area, provide a non-discrimination, diversity, and non-harassment policy at the time of intake, and it's really important to post the non-discrimination statements as well. You want to utilize LGBT-friendly symbols, and of course, display LGBT-relative literature among other brochures that you might have in your office. Again, it's important to train every staff member in your medical practice, and those frontline staff can sometimes have the biggest impact on patients, right? You want to, again, train all staff to be very welcoming and non-judgmental, and again, do not limit that training just to the medical staff. You want to educate your frontline, your, you know, all the different staff members that you have in your practice. Encourage staff to politely hold each other accountable. If you notice someone using wrong pronouns, it's very important to politely correct. And the main goal is to make transgender patients feel safe and welcome. So I would now like to introduce my esteemed colleague, Dr. Mira Menon from The Ohio State University, who will be discussing important laws and legal issues faced by some of our transgender patients. Dr. Menon. Thank you. So the purpose of this section is to provide an overview of the various legal barriers that transgender individuals may face, needing to navigate the various regulations that local, state, and national levels can be a significant source of stress for our transgender patients. I intend to describe legal considerations in various facets of life. I'm not a lawyer, and so I do not intend to provide any legal advice. And the regulations that I will be discussing are current as of the date of this recording in March 2021. Some but not all trans folks may seek to legally change their names. These laws do vary state by state. One example is that it's not uncommon for courts to require medical or psychiatric documentation, even though this may not be required for other types of name changes. For example, when an individual gets married and wishes to change their name. It's also common for individuals to need to post a legal notice of a name change in a newspaper. While this latter policy dates back to fear of using a name change for fraud purposes, there is a greater and more realistic concern about privacy and protection from hate crimes. Some states also require one or more proofs of residence, photo identification, a long form birth certificate, a background check, and or notification of creditors via registered mail. All of this information can be costly and time consuming, and it's very possible that our trans and gender diverse patients may not have readily access to these documents. So when it comes to gender marker changes on birth certificates, the process also varies state to state and can be cumbersome and confusing to navigate. Tennessee and Ohio are the two states that do not permit gender marker changes on birth certificates. In Ohio, actually, this restriction was struck down by a federal judge in December 2020. However, implementation procedures for this have not yet been established. 17 states require a court order, whereas 31 states have a process that do not include a court order. Only 10 states do not have a medical evidence requirement for gender marker changes. 14 states require some sort of medical assessment, while 15 states require proof of surgery. This is important to note, as not all trans and gender diverse individuals undergo medical interventions or surgical procedures, and needing this requirement is certainly a barrier. Nine states have no specific policies surrounding medical evidence requirements for a gender marker change on one's birth certificate, which can cause confusion about which documents are needed. 10 states do permit a gender neutral designation of X, which is especially helpful for individuals who do not identify as male or female. So, when it comes to driver's licenses, all states permit a gender marker change on driver's license, but the difficulty level certainly varies. Some require birth certificate change and certification from a licensed professional or medical provider. Other states have unclear policies, and again, the lack of clarity impedes the process of getting a license changed. Moreover, with the issue of the birth certificate change, if you're living in a state where you can change your driver's license gender marker, but you were born in a state where that is not a possibility to change it on your birth certificate, that would prevent you from being able to change that gender marker on your current driver's license, which can lead to a great deal of stress when it comes to any number of occasions when we're asked to present our licenses or identification. So, when it comes to the driver's license, there are still nine states that require proof of surgery to permit the gender marker change on a driver's license, and 19 states permit a gender neutral marker option of X. Other states are moving in this direction to better represent individuals who do not identify as male or female. The National Transgender Discrimination Survey was published in 2011 and examined discrimination among trans and gender diverse individuals on a wide scale. I do recommend that you take a look at this because they have a lot of striking information. Having proper identification is very important and meaningful. When it came to identity documents, they found that in presenting identifications, 40% of respondents faced harassment, 15% were asked to leave an establishment, and 3% were assaulted. The survey also noted that individuals of higher socioeconomic status or who were members of a majority racial or ethnic group found it easier to change documents. I now want to talk about various rights that transgender individuals or gender diverse individuals have in a variety of different facets. For marriage, Obergefell et al. v. Hodges, which was ruled in June 2015, is the landmark Supreme Court case that ruled on the issue of same-sex marriage. This determined that a person's sex cannot determine their eligibility to marry a person of either gender. Many think of this ruling as pertaining to cisgender same-sex couples. However, the ruling made the issue of marriage gender blind. However, there are still plenty of issues faced by trans and gender diverse individuals related to marriage. Some courts challenge certain parent-child relationships, for example. Not all state officials will provide a marriage license. Many states' marriage licenses still use gendered language such as bride and groom. Some officials may insist that a person's name and gender be registered according to what is listed on identity documents, even if that information is no longer accurate. The R.G. and G.R. Harris Funeral Homes Incorporated v. Equal Employment Opportunity Commission is the landmark Supreme Court case that ruled on an employer's ability to discriminate against an employee based on their gender identity. In 2013, Amy Stevens informed her employer of her identity as a transgender woman and of her intention to present as such in the workplace environment. She was fired for this two weeks later. She sued for sex discrimination in the workplace, and seven long years later, the U.S. Supreme Court ruled that Title VII of the Civil Rights Act of 1964 did protect transgender people from employment discrimination. Prior to this ruling, courts across the nation had varied rulings about an employer's ability to discriminate against someone based on their gender identity or their sexual orientation. Healthcare protections have fluctuated significantly over the past several years. Every major medical association, including but not limited to the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatrists, the American Academy of Pediatrics, the World Professional Association for Transgender Health, all of these and others support gender-affirming treatments for transgender individuals. This is in sharp contrast to the false assumption that these treatments are experimental or merely cosmetic. In 2016, it was clarified in Section 1557 of the Affordable Care Act that non-discrimination on the basis of sex includes gender identity. It was one of the first governmental acts to include this non-discrimination policy. The document describes, we propose that the term on the basis of sex includes but is not limited to discrimination on the basis of pregnancy, false pregnancy, termination of pregnancy or recovery therefrom, childbirth or related medical conditions, sex stereotyping, and gender identity. However, in June 2019, the Health and Human Services removed non-discrimination protections for the members of the LGBT community. The Director of the Office for Civil Rights in the Department of Health and Human Services reported that the definition of on the basis of sex would return to only encompass biological sex. One landmark case is Boyden versus the State of Wisconsin. This case was trialed in federal trial court. And in it, two state employees who were trans women filed lawsuits due to the fact that their health insurance companies would not cover medically necessary gender-affirming treatments. Two plaintiffs were, the two plaintiffs filed lawsuits against Boyden and Boyden Two plaintiffs were, the two plaintiffs were awarded a collective $780,000 to be paid by the State of Wisconsin to compensate for the cost of surgery and for discrimination. By executive order earlier this year, President Biden declared the following, it is my conviction as commander in chief of the armed forces that gender identity should not bar an individual, be a bar to military services. Moreover, there is a substantial evidence that allowing transgender individuals to serve in the military does not have a meaningful negative impact on the armed forces. It's really notable how easily one's ability to bravely serve in the armed forces can be so easily changed by executive order. Indeed, there is no evidence that being transgender would negatively impact one's ability to serve in the military. Equality Act. So the above non-discrimination protections that I just discussed have been made largely via court decision or through executive order. As administrations change, so can these regulations, which can certainly provide a great deal of stress for the individuals that these regulations are meant to protect. On a state level, only some states have laws prohibiting discrimination on the basis of gender identity. Additionally, laws and regulations surrounding name change and gender marker changes do vary significantly state to state and are confusing and costly to interpret and implement. In an effort to codify these protections, the United States House of Representatives passed the Equality Act on February 25th, 2021. As of the date of this recording, this act is under review by the Senate Judiciary Committee. This act provides non-discrimination protections for members of the LGBTQ community in areas including employment, housing, credits, education, public spaces, public services, federally funded programs, and jury services. So of note, it also expands the definition of public spaces and services to include retail stores, banks, or legal services, and transportation. If these laws were passed, it would be much harder to threaten the above protections that have been promised by various court cases and executive orders. Our transgender patients and friends could rest a lot easier knowing that there are consistent non-discrimination protections tattooed into the law of our country and that can help them when they travel between state lines. So in our next section, Dr. Jessica Porcelan will discuss current practice models in transgender and gender diverse health care. Thank you. Thank you so much, Dr. Menon. For my part of the presentation, I hope to build on some of the concepts that were already introduced through a case. So let's just jump right into it. In our case, we have a 24-year-old Asian American transgender man who presents to a psychiatrist to quote, prove I am transgender so I can get started on hormones. So when we have a patient like this come into our office, it really should be our goal to provide gender-affirming care. So we might ask ourselves, how do we actually do that? I think it's easiest to conceptualize the various styles that psychiatrists have among a continuum. And so here's a continuum that I need for you. You can see less patient autonomy to full patient autonomy. And the first model I would like to discuss is the gatekeeper model. And what I mean by this is, you know, what you could envision is a psychiatrist standing with their arms crossed saying, no, you shall not pass until you answer all of my questions. And if you answer them correctly, then maybe I'll let you through the gate in order to get the treatment that you deserve. This is in stark contrast to the informed consent model, which is a more collaborative approach between the patient and the psychiatrist in order to get the patient towards their goals. Obviously, these two models have positives and negatives. So let's start to work through some of them. The first positive for the gatekeeper model is it's extraordinarily thorough. When doing an assessment using the gatekeeper model to assess somebody for gender dysphoria, sometimes these assessments can take up to eight hours. So that's obviously quite time intensive, both for the psychiatrist and for the patient. Additionally, with the gatekeeper model, sometimes the patient might develop a distrust for mental health. And the reason for that is the patient would really see the psychiatrist as a barrier rather than an ally to help them get the care that they need. Let's move over to the informed consent model and work through some of the positives and negatives here. As I previously mentioned, one of the positives is it's quite collaborative. In the informed consent model, we as psychiatrists are really here to assist the patients in making their own decisions. This approach recognizes that patients themselves and their personal lived experiences are best to assess and judge the potential improvement a transition could provide for them. One possible negative is an increased risk for misdiagnosis. In general, the informed consent model is less thorough, less time intensive. And so what I mean specifically by misdiagnosis is missing co-occurring conditions like depression and anxiety. As you can see all the way to the right here, hormones on demand, I purposefully put that outside of the continuum because this is really not a recommended style of practice. What I mean by hormones on demand is a patient would walk into an office and say, I want testosterone and the doctor would just provide them testosterone without asking any questions. This approach is not recommended because it really removes our ability as psychiatrists to do, to use our clinical judgment and do thorough assessments. I would like to emphasize that the informed consent model is the preferred practice model, as outlined by WPATH. And Dr. Walters will talk more about WPATH in just a moment. So thinking back to our case that we started with, we would imagine that that patient was likely worried that the psychiatrist would be using the gatekeeper model because the patient felt like they had to prove something, to prove that they were transgender to the psychiatrist. Okay, so I know that was a lot of words. Now, hopefully we have a better understanding of the continuum of practice models. So let's quickly jump back to the case for a little bit more information. All right, so the patient is currently homeless, living on his friend's couch. He was kicked out of his parents' house after sharing his gender identity with them. Up to this point in his life, the patient presented as a woman. Recently, he's been looking for a new job so he can have a, quote, fresh start as a man. He reports, I wish I wasn't trapped in the wrong body. It would be easier. Okay, so with this new information, I think it really brings a very, very important concept up, which is the minority stress model. Dr. Gentile introduced this at the beginning, and I would like to take this time to go into a little bit more detail. So different aspects of the person's identity, and for our case, the fact that he's Asian American, the fact that he's transgender, means that he will have different experiences due to the fact he's a member of a minority group. These experiences can really be broken down into internal and external stressors, and those internal and external stressors mediate one another. So when we think about the case, we think about the external stress of rejection and discrimination, and those really mediate his internal experiences, like stress, feeling like he needs to conceal his true gender identity, and with all of that in mind, I think it becomes quite apparent how these experiences, these stressors, can then lead to poor mental health outcomes. And understanding the poor mental health outcomes as a framework, using the framework of the minority stress model, I think it really highlights how paramount it is that we provide gender-affirming care. All right, let's take a step back for a moment. For me, the minority stress model can be quite challenging, so let's use a quick example. So you come across this desert island, it's in the middle of the ocean, and when you arrive, 90% of the people on this island are transgender, and 10% of the people are cisgender. I would encourage you to think about how would transgender people on this island be treated in their society? Would they have the same stress, external stigma, as transgender people have in our society? What do you think their mental health outcomes would be since they're part of the majority in their society? Those are just some questions I wanted to throw out for us to think about as we move forward. We as psychiatrists have to recognize that we are vital to this cultural shift, to destigmatizing this patient population. The chart here is from a study by Bradford in 2013, and what this was was a statewide study where 350 self-identified transgender people completed a needs assessment. And what I want to highlight in this is that healthcare, one in four people reported that healthcare was contributing to their external stigma-related stress. So you might be wondering what specifics about healthcare are contributing. So let's quickly jump back to the case to highlight some of this. The patient says, I didn't even tell my family doctor for nearly a year, and then when I did, I had to teach the doctor about trans stuff. The patient goes on to report I didn't have access to hormones due to being unable to find a doctor who could help me. The patient says I started to buy tea or testosterone online. So I think the Bradford study that I previously mentioned out of Virginia really highlights that our patient in our case is not alone. 43% of people were out to their PCP, meaning the majority of transgender people have not told their PCP that they're transgender. 20% feel the need to educate their PCP on their healthcare needs, and 15% are uncomfortable discussing transgender-specific healthcare needs. Another important healthcare-related stressor is their lack of access, and I know this has previously been mentioned, but here are some statistics from that same study showing the lack of access is for a wide range of things like hormonal treatment, transgender-related surgery, psychotherapy, as well as gynecological care. So another component of healthcare-related stress brings us back to this continuum. And everyone, this should look familiar, right? This is what we started my part of the presentation with. I think it's really important that if we practice too far left, too paternalistic, we need to be aware that we might actually be contributing to minority stress model through external stigma. All right. So now that we have a good understanding of the various stressors in the minority stress model, let's move on to mental health outcomes. And we'll use our case to exemplify some of this. The patient reports anxiety and depression, stating, the depression used to be so bad, I didn't see the point in living. The patient explains these feelings were most severe four years ago. He endorses a suicide attempt by overdose at that time, saying, I woke up the next morning and I just didn't tell anyone. He says these symptoms are manageable now. So in this case, obviously our patient is reporting co-occurring conditions like depression and anxiety, as well as a suicide attempt. And we'll get into those specifics in just a moment. But I wanted to take a second and do a 30,000 foot view of serious psychological distress. And I use this figure, it's from a 2015 transgender survey. This was nationwide, all 50 states, and it had a huge sample size, an N of over 27,000. And let me quickly just orient you to this chart and we can get into it. So on the X axis here, you can see the various age groups. And on the Y axis, you can see the percentage of people who endorse serious psychological distress. The blue bar is transgender people and the white bar is cisgender. And so I think this is a visual representation of the significant health, the significant discrepancy between transgender and cisgender. I also wanted to point out that you can see the discrepancy is at its most in this younger age group. And if you remember back to our case, our patient was 24. So in this younger population, 18 to 25, and even 18 to 30, we need to be very much tuned in to the different psychological distress that transgender patients might be experiencing. Okay, as I promised, we'll do statistics on depression and anxiety. So this is a chart from a Massachusetts study. This was also a statewide study in 2009, smaller sample size, the N value for transgender was 59. And as you can see here, this chart is showing the number of depressed and anxious days in the past month. And for transgender status, yes, so this row would be transgender and the transgender status no would be for cisgender. So you can see that transgender people have nearly double the number of depressed days compared to cisgender. And you can also see that this discrepancy occurs as transgender people have more anxious days in comparison to cisgender. So, you know, when we see studies like this, it really makes me ask why, why, what are the factors contributing to the person's depression? And jumping back to that Bradford study in Virginia, the two factors that they found in their study that were contributing to depression were severity of discrimination, and the lack of their own identity acceptance. And as soon as you see those things, I'm hoping your mind's going minority stress, minority stress, right back to this model. And so for the stressors here, these two factors, severity of discrimination is external stress and the lack of their own identity acceptance is internal stress. Okay, hopefully I put stopped the minority stress model enough. I do want to touch on suicidal ideation and attempt since that was a component of the case that we've been working through together. Once again, this is from the Massachusetts study. And you can see here that it's 30% of transgender people had suicidal ideation compared to 3% of cisgender people. And that's a tenfold increase. To me, those numbers were very, very striking. And so I took a peek at the bigger study with the end of 27,000. And we saw very comparable things in this study, 40% of transgender people had attempted suicide at some point in their life compared to the 4% of the U.S. population. So once again, there is that tenfold increase in suicidal ideation and attempt in transgender. Okay, hopefully we weren't too bogged down with statistics there at the end. I wanted to wrap things up with just a few take home points. So first, the informed consent model is preferred, remembering that if we practice as gatekeepers, we could actually be contributing to the external stress and stigma for our transgender patients. Second is mental health disparities exist. We know that our case, we walked through depression and anxiety as well as suicidal ideation. And due to time, I didn't even touch on things like substance use, intimate partner violence, as well as things like increased risk of HIV or STIs. And so it's so, so important as psychiatrists that we screen these patients appropriately. And my final take home message is that the minority stress model really is our framework to understanding why, why, why, why transgender people have poor mental health outcomes. All right, now I'm going to pass it on to Dr. Walters. He is going to walk us through the WPATH standards of care and provide us with tangible skills of how to appropriately write a letter to insurance to support gender affirming surgery. Thanks so much, Dr. Porcelain. So now with those important disparities in mind, as well as an understanding, a deep understanding hopefully as to why they exist, let's move on to talking about what we can do in our roles in psychiatry to take steps to ameliorate them and hopefully also form a deeper alliance with our transgender and gender diverse patients. So for those unfamiliar with WPATH, it's the World Professional Association for Transgender Health. It's been around since 1979, it was started by Dr. Harry Benjamin, it actually used to be called the Benjamin Standards of Care. So WPATH has developed a comprehensive standards of care that have worked to advocate on behalf of trans persons and also trying to ensure the competency of mental health and medical professionals. The seventh edition, which is the most current edition, was published in 2012. They have, again, seven editions since 1979, so it continues to evolve to include recommendations based on growing literature and the evidence based throughout medicine. Again, these are standards of care and ethical guidelines, and they cross professional boundaries. There are certain sections that are based on surgery, psychiatry, and mental health providers, as well as endocrinology, family medicine, it's really all encompassing. The nice thing is that it's readily available online as a PDF document for free. So as a provider, you can go and kind of scan down to the sections that really pertain to you, but also be aware of the other sections as well. It's an important caveat that these are standards that provide guidance rather than rules or an algorithm, and the manner in which that they're embraced or not embraced can really vary based on institutions, provider preferences, and comfort levels, and they're certainly not always upheld or adhered to by insurance companies. So let's hone in on mental health. So the tasks for mental health providers as laid out by the standards of care are quite straightforward and pretty brief. So we've really, I think, covered a lot of it today in this presentation already. So going through our tasks, being able certainly to provide a diagnosis of gender dysphoria per DSM-5 criteria, should that be something that pertains to the individual, as well as, of course, screening for coexisting mental health conditions. They go through a list that are most important. Again, I think this is already wrapped into our role in terms of providing evaluations for patients. Furthermore, a task is to be able to provide information regarding options for gender identity and expression and possible medical interventions if patients are seeking that. And then, you know, kind of right along the tail of that is assessing eligibility, preparing and referring for hormone therapy or steps in surgical transition, if that's appropriate, and being able to provide that referral, and we'll talk a little bit about that later. Also being able to educate and advocate. This is my favorite part of, I think, working with trans and gender diverse patients is that advocacy is really an integral part of clinical practice. So being able to advocate on behalf of clients within their communities. We talked a lot earlier about what this looks like and what society looks like as for trans individuals. And then also being able to assist in making identity document changes. Some changes such as having your name or gender marker changed on your passport, for example, is there's a document for physicians to fill out and provide to patients, you can find that right online. An important note, it is now considered unethical, both by the APA and most psychiatric organizations to aim any treatment at trying to change gender identity to match the sex that was assigned at birth. This is commonly called conversion therapy. And research really strongly supports that it wasn't successful anyway, but it's really paramount that you're aware that it does remain legal in many states. So thinking about how can we turn these guidelines, how can we turn all that we've learned today into some action? I think it's great when you go to a session that you walk away with a new skill, or at least maybe a seed planted to grow that skill in your career. So thinking as psychiatrists, we're already engaged in training, you know, throughout our careers to provide really comprehensive diagnostic evaluations for all kinds of complex psychiatric pathologies. And writing a letter for support for gender affirming surgery really takes moments but can have an immense impact. I think this is really one avenue where psychiatrists can really readily explore stepping into that role of patient advocacy. And again, keeping in mind that yes, this does create that gatekeeper bottle, right, that you can exist as a gatekeeper, because that is the position that our current society and our current medical system and current insurance reimbursement puts us in, while practicing that informed consent model. And so thinking even beyond this, this is sort of how I conceptualize a first step that we can make toward providing gender affirming care. You know, doing this evaluation may take an hour of your life, writing the letter may take a few more moments, but it can really have an immense meaningful impact on a transgender or gender diverse person's life. And beyond this, and perhaps even further reaching, as Dr. Porcelain was kind of alluding to, is that we may really be able to impact the alliance between TGD folks and psychiatry or mental health as a field. And that relationship is already one that's tenuous given our history. So I encourage you to consider when you think about engaging in this practice, performing this service, building this alliance, being more gender affirming in your careers, what comes up for you, right, getting curious, what's coming up in terms of your thoughts around this? What barriers can you identify that exist to providing this as part of a diagnostic interview? As a resident, just as an aside, I chose to actually train at an institution that didn't have these services embedded within our psych department. And with the support of my department, I was able to create an outpatient consultation clinic aimed at providing these evaluations and writing letters of support. And again, this was pretty low in terms of the requirements on my time, on our department's time, a one-time hour-long consultation evaluations with follow-up if necessary, but was rarely required. And again, it's important to view this as kind of just the first step, meaningful step to not only improve access to care for transgender folks, but also to begin to reshape that alliance between psychiatry and gender minorities. So again, to leave you with a concrete skill to hone in after this session, I'm going to give you an overview of the evaluation and letter writing process. I think when we begin to approach it, it's great to have some more background information and context. I think this in general was really emphasized here today, so I won't spend too much time going over it. But I think remembering again that this gatekeeper role has really been established by insurance companies and a bit by the WPATH standards of care as well. And hopefully as society and as medicine continues to progress, this won't be required in the future, but this is where we are for now. Per the WPATH standards of care, a patient who's seeking a gender-affirming top surgery, for example, the case we were talking about, if that trans man was seeking a gender-affirming mastectomy, for example, the WPATH would say that that patient would need one letter of support and a referral for this top surgery. And per the WPATH standards of care, two referral letters of support are required for bottom surgery. This varies greatly. I practice in two states, and the range of which different insurance companies, different providers, different institutions adhere to this is very different. I've had lots of patients need two letters of support for top surgery. I've even had some patients have their insurance tell them that three letters were required. So again, this can really vary. And thinking about that, if you are a patient that's not engaged in mental health services now, having access to finding two providers to write these letters is pretty tough. A lot of patients will come to see me, they've already had a therapist that's going to write a letter, and maybe I'm the second letter. But again, this is about being a psychiatrist that's able to provide this to improve that access. Again, like we said, being aware of that gatekeeper role, knowing that the patient may be coming in, when you hear that a patient's chief complaint is, I'm here to prove that I'm trans so that I can take a step to be in a body that feels more authentic to my gender identity, is pretty powerful in terms of the dynamic that's already set up between you and the patient. And that ties right into those possible implications for pathologization, which we talked about earlier too. And so really embracing our own roles in reducing that stigma. I'll talk directly with patients around my hope that in the future, these evaluations aren't required and make it a very gender affirming and empowering evaluation for them with a very concrete goal, a successful step in transition for them that should be covered by insurance. And that leads to another piece as well around diagnosis. We talked earlier about how not all transgender patients have gender dysphoria. Generally that is the diagnostic code that insurances want to see to accept for steps in medical or surgical transition. And that's something that I encourage you and that I talk directly with patients about. And for most of them, they say, yeah, that fits. There are aspects of my body that I am uncomfortable with, which is why I'm taking these steps to change that, to feel more aligned and authentic. But really being transparent about that I think is important. And finally, as just more context, I hope that most of you are informed with how to kind of take a trauma informed approach. We just went over a bunch of the different disparities that are experienced by trans and gender diverse individuals. Trauma is a huge one. There was a great article that came out in 2011 by Grant et al that found that within the medical setting, again, these are trans or gender diverse people going to a medical appointment, 28% of them reported harassment, 19% were denied care, and 2% experienced violence in the medical setting. Imagine going to see your PCP and being a victim of violence as a result. So again, using that trauma informed approach, understanding the society and how this group of individuals has been treated, both within society and the medical setting over history, and being really sensitive to that. All right, so more concretely now, thinking about writing this letter, consider what might be important to include. And finally, are patients identifying characteristics, and again, these are all per the WPATH standards. Kind of results and diagnostic evidence as found in your evaluation, how long you've been working with them, kind of where they're at in the transition process, and talking about informed consent. So with all of these six things, I really think you can boil it down to three things and doing these evaluations, I think it really boils down to one, do they meet criteria for gender dysphoria per the DSM-5 criteria that's not better accounted for by another diagnosis, something like a delusional disorder, an eating disorder, a body dysmorphic disorder. So again, that diagnostic piece, and that's something, again, that I discuss with the patient as well. And number two, is there evidence of psychiatric stability, that this person is in a place where they'll be able to be successful in going through a surgical procedure and recovery, or beginning hormone therapy. These are things that we, again, are really inherent in our role as psychiatrists, is there active suicidality, homicidal thoughts, evidence of psychosis, anything that's really severe that would prohibit them from being able to be successful in the process. And the third thing being, is there capacity to make that decision for surgery or medical treatment. I think we're all pretty familiar with doing capacity evaluations, but is there consistent choice, is there understanding of risks and benefits, do they feel comfortable talking to their surgeon or their provider, maybe their endocrinologist, about the risks and benefits, do they feel they've had their questions answered, is there adequate support for recovery. And within that kind of statement of capacity, I would also include a statement of medical necessity, that's really the big key words that insurance companies like to see. So finally, I think it's great to see this synthesized all together, I've included a sample letter that I've used, completely de-identified, to review. This is something I'm happy to share with others, if you're interested in getting into this work, or the way that I've made this, you can do a really quick online search and see some of the templates from some of the other gender-affirming clinics throughout the country. So again, this first paragraph, you've got your identifiers, and the part's in red, right, do they meet criteria for gender dysphoria per the DSM-5 criteria, not better accounted for by another diagnosis. You could make a comment on where they've been in terms of transition thus far, if it's someone already taking hormones, how long they've been on them, if they've had other surgeries to date, and what they're seeking now in terms of a gender-affirming surgery. The next paragraph is very short, and it's your clinical assessment, is there adequate evidence of psychiatric stability? I choose to really put in what's minimally required, I wouldn't divulge other diagnoses, really all that needs to be there is your clinical assessment around stability. You could also, if someone is engaged in ongoing mental health treatment, therapy, or med management, you could also include that if you felt that to be important. The third paragraph, again, talks to that capacity aspect, are insight and judgment sound and good, do they have full capacity? Important caveat, through most of our presentation today, we've been talking about the adult population. This applies with a bit of tweaking to children, but of course, in this section, you'd also have to put in assent and consent in terms of parents being on board as well. We won't get into that, because that gets a lot more complex, but again, this same template could be used. Then whether or not you're in favor of supporting this recommendation, so that last paragraph is really, I've met with this person for however long, or if it was one day, and declaring the medical necessity of it as well. With that, in closing, here's our compiled references, I'll walk through these for you, but overall, we thank you all so much for your time, your attention, and your choice in viewing our session. We hope that it's been at least educational, if not inspiring, a new or a renewed passion for embracing gender-affirming care in psychiatry, so thanks so much.

Transgender Affirming Care

Psychiatrists

Transgender patients

Mental health resources

Access to healthcare

Stigma and discrimination

Gender diversity

Mental disorder classification

Neuroanatomical variations

Gender affirming care