Transgender Patient Care

Definitions1
Sex - A term used to classify people typically Sexual Orientation - A person’s sexual identity Trans Man - Term used for people assigned
as female or male, usually based on external in relation to the gender(s) to which they are female at birth, but identify and live as a man.
anatomy at birth attracted.
Trans Woman - Term used for people assigned
Gender Identity - A personal conception of Gender Expression - The external display of male at birth, but identify and live as a woman.
oneself as male or female, both, or neither. gender through name, pronouns, appearance,
and behavior.
Non-binary - An umbrella category for trans
Transgender (Trans) - A term for people Cisgender - A term for people whose gender persons who do not conform to binary (i.e. wom-
whose gender identity does not coincide with the identity coincides with the sex assigned at birth. en or men) genders. More specific labels may
sex assigned at birth. Incidence steady since 201610 include genderqueer or gender fluid. Non-binary
youth (13-17) - 1.8% in northeast to 1.2% in midwest people often use gender neutral pronouns such as
adults - 0.6% in northeast to 0.4% in midwest they/them/theirs, ze/zir/zirs, or ne/nem/nirs.

Gender Dysphoria (DSM-V) Interviewing and Treatment Considerations

≥ 2 symptoms for ≥ 6mo + clinically significant distress or so-
cial/occupational impairment
• incongruence between one’s experienced expressed gender and pri-
mary/secondary sex characteristics
• strong desire to be rid of one’s primary/secondar sex characteristics
because of marked incongruence with one’s experienced/expressed
gender
• strong desire for primary/secondary sex characteristics of the other
gender
• strong desire to be of alternative gender different from one’s assigned
gender
• strong desire to be treated as another gender
• strong conviction that one has the typical feelings and reactions of
the other gender
Problems with the diagnosis:2
• may be perceived as pathologizing
• lack of a diagnostic code for trans patients who no longer
experience significant distress or social/occupational impair-
ment
Environmental Considerations
Institutional Practices
• intake and registration forms include options outside of
typical gender binary or heteronormative context can convey
openness and inclusivity3
Use of preferred names and pronouns,4
• Document disparity between legal and preferred names
early in hospitalization
• Treatment team and staff should use patient’s preferred
name and pronoun
Rooming3,4
• Should room transgender patients with others of same gender
identity, rather than assigned sex
• Avoids feelings of invalidation, traumatizing, and dis-
crimination to the trans patient, and can avoid confusion
from the roommate
• Considerations
• clinical needs/wishes of potential roommates
• the risk/benefit of disclosing transgender patient’s gender
identity
• risk of aggression or violence toward the LGBTQ patient
• If not possible, assign a private room
• Can be isolating and lead to adversarial relationships with
peers in the same setting who are subjected to having a
roommate
Establish basic understanding of patient’s gender journey
in order to provide appropriate inpatient care and properly
assess risk of psychiatric illness
• Potential violence and harassment from family members3
• family rejection associated with higher reports of:5
• suicide attempts (8.4x)
• high levels of depression (5.9x)
• use of illegal drugs (3.4x)
• unprotected sex (3.4x)
• Any formal or informal attempts by others to change gender
identity or sexual orientation
• 17% of LGBTQ threatened with or subjected to conver-
sion therapy → 2.5x the rate of attempted suicide6
• formal and informal attemps assoc. with:7
• ↑ depression
• ↑ substance use/abuse
• ↑ unprotected sex
• ↓ educational attainment
• Ask about support system from friends or significant others,
especially if family is not supportive
• Ask about employment and health insurance as Sexual mi-
nority women and men were about twice as likely as their re-
spective heterosexual counterparts to have been unemployed
and uninsured8
• Never appropriate to directly ask patients about their genitals
when inquiring about sex-related medical needs
• “In order for us to better understand your medical histo-
ry, what steps have you taken toward physically transi-
tioning?”
• “Is there anything that we need to know about your tran-
sition that is related to your medical treatment here?”
• Ask if patients are currently taking or have previously taken
gender-affirming hormonal treatments to ensure continuity of
care
• overall limited evidence about long term impact of hor-
monal therapy, but it is associated with increased QOL,
decreased depression, and decreased anxiety9
• Inquire about non-pharmacological gender-affirming ap-
proaches patients may use to help them feel more comfort-
able: chest binders (for hiding breasts), packers (for simulating
male genitalia under clothing), prosthetic breasts etc
• loss of access to gender affirming care may be a driver of
despair and suicidal thoughts
References
1. Quick tips for medical providers of transgender patients. University of Iowa Hospitals & Clinics https://uihc.org/health-topics/quick-tips-medical-providers-trans-
gender-patients (2017).
2. Dickey, I. M., Dan H. Karasic, & Nathaniel G. Sharon. Mental health considerations with transgender and gender nonconforming clients | Gender Affirming Health
Program. UCSF Transgender Care & Treatment Guidelines https://transcare.ucsf.edu/guidelines/mental-health (2016).
3. Fadus, M., Hung, K. & Casoy, F. Care Considerations for LGBTQ Patients in Acute Psychiatric Settings. FOCUS 18, 285–288 (2020).
4. Saw, C. Transgender Patient Care on the Inpatient Psychiatric Unit. Am. J. Psychiatry Resid. J. 12, 7–8 (2017).
5. Ryan, C., Huebner, D., Diaz, R. M. & Sanchez, J. Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual
Young Adults. Pediatrics 123, 346–352 (2009).
6. 2022 National Survey on LGBTQ Youth Mental Health. The Trevor Project https://www.thetrevorproject.org/survey-2022/.
7. Ryan, C., Toomey, R. B., Diaz, R. M. & Russell, S. T. Parent-Initiated Sexual Orientation Change Efforts With LGBT Adolescents: Implications for Young Adult
Mental Health and Adjustment. J. Homosex. 67, 159–173 (2020).
8. Charlton, B. M. et al. Sexual orientation-related disparities in employment, health insurance, healthcare access and health-related quality of life: a cohort study of
US male and female adolescents and young adults. BMJ Open 8, e020418 (2018).
9. Baker, K. E. et al. Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. J. Endocr. Soc. 5, bvab011 (2021).
10. Jody L. Herman, Andrew R. Flores, & Kathryn K. O’Neill. How Many Adults and Youth Identify as Transgender in the United States? https://williamsinstitute.law.
ucla.edu/publications/trans-adults-united-states/ (2022).