Our profession has a number of obstacles to overcome in gaining the trust of transgender and gender non-conforming patients. We turn to this month’s expert, Jack Drescher, to better understand how to work with this population.

TCPR: Tell us about this new diagnosis, gender dysphoria, and what it means for patients.
Dr. Drescher: In DSM-IV, identification with the other gender was itself a mental disorder: gender identity disorder. That added stigma to a group that already experiences a stigmatized identity. That part is changed in DSM-5. The manual explicitly states that gender nonconformity in itself is not a mental disorder, but it retains a diagnosis for those for who experience distress and dysfunction due to incongruence between their experienced and assigned gender: gender dysphoria, without the word “disorder.”

TCPR: Why not take out the diagnosis altogether?
Dr. Drescher: The challenge we faced in the DSM-5 work group was to reduce stigma while maintaining access to care for patients who have a diagnosis of gender dysphoria. Removing the diagnosis completely would limit access to care for these patients, which includes access to endocrinology consultation and gender reassignment surgery. A different approach would be to remove the diagnosis from the manual of mental disorders but still include it as a medical condition. The World Health Organization has moved in that direction with ICD-11. There, the diagnosis is called “gender incongruence.” I am on the WHO work group that recommended moving that diagnosis from the chapter on mental disorders into a new chapter called “Conditions Related to Sexual Health.” The World Health Organization Assembly will vote on the entire ICD-11 revision in 2019.

TCPR: That makes sense, as the treatment for gender dysphoria has shifted into the medical realm with our endocrine and surgical colleagues. Those colleagues are also calling on us to screen patients before gender reassignment surgery. How should we fulfill that role?
Dr. Drescher: Historically, the role of psychiatrists and other mental health professionals in the treatment of transitioning patients was that of gatekeepers; that is, to make the determination about whether or not a patient should have access to care related to their gender identity. That is no longer the case regarding access to hormone therapy. However, there are many surgeons, for example, who are unwilling to accept a request for reassignment surgery without a mental health professional writing a letter. Many times, the surgeon may require that the letter be from a psychiatrist or mental health professional who knows the patient, has been working with the patient for some time, and can attest to the diagnosis of gender dysphoria. A surgeon might also request a second letter from an expert, who may not know the patient very well but has seen the patient in consultation. Today, it is the surgeons and some insurance companies who want mental health professionals to act as gatekeepers.

TCPR: What factors would steer you away from endorsing a patient’s request for gender reassignment surgery?
Dr. Drescher: It’s a challenging question. The issues are whether there seems to be a stable state of mind, whether the patient meets diagnostic criteria for gender dysphoria, and whether it seems reasonable to assume that the gender dysphoria would be improved with surgical treatment. For example, if a patient presents with psychosis, does gender dysphoria still persist when the patient is not in a psychotic state? One way to make that assessment is through treatment. For example, before recommending surgery, does something such as testosterone treatment relieve their anxiety and make them less dysphoric? And if so, does the patient still want a double mastectomy as part of the transitioning process?

TCPR: So, it sounds like a big part of the assessment is providing some reassurance to our surgical colleagues that this procedure is actually going to help the patient, and that the patient won’t be worse after the procedure and will be happy they had it?
Dr. Drescher: Right. The major preoccupation in this area is concern about regrets, but psychiatrists are not always very accurate at predicting whether or not someone will regret transition. Yet the whole gatekeeping system is set up to try and prevent regrets. However, it’s not a perfect process, and serious questions have been raised over whether everyone should go through the psychiatric evaluation process.

TCPR: Do we have research on what outcomes look like after surgery in terms of regrets?
Dr. Drescher: There’s not a lot of research in the U.S. A study in the Netherlands looked at outcomes in over 6,000 patients who underwent reassignment surgery. The rate of regret was very low: 0.6% for transwomen and 0.3% for transmen (Wiepjes CM et al, J Sex Med 2018;15:582–590).

TCPR: At what age does the medical field now consider it acceptable for a patient to undergo either surgical or hormonal transition?
Dr. Drescher: Well, it varies from country to country. I think in the U.S. nobody will perform surgery before age 18. In some countries it might be younger. It really depends on what the age of consent is for adulthood. In the U.S. now, some physicians are providing hormones for gender transition as young as 12. I don’t think that is the case everywhere. I think most physicians are waiting maybe until age 15 or 16 before they will give hormones.

TCPR: Can you tell us about using hormones to delay puberty in someone with gender dysphoria?
Dr. Drescher: Puberty suppression or puberty blocking is an intervention that was perfected by the Dutch at the gender clinic in Amsterdam. It was based upon the clinical observation that some kids become panicky and suicidal about developing secondary sex characteristics as puberty approaches. So, children assigned female at birth—who identify as male—might not want to have menstrual periods start or to develop breasts. Children assigned male at birth might not want to have the typical male growth spurt, develop an Adam’s apple or beard, or have their penises grow. So, the Dutch introduced puberty suppression medications more than 20 years ago, and now it’s being done everywhere around the world. Puberty suppression prevents those changes related to assigned gender from happening.

TCPR: What are some of the benefits to puberty suppression?
Dr. Drescher: It’s not always clear which prepubescent children will continue to be gender dysphoric as they age into adolescence and which ones will not. The children whose gender dysphoria persists are called persisters, and the ones whose gender dysphoria goes away are called desisters (Steensma TD et al, J Am Acad Child Adolesc Psychiatry 2013;52:582–590). The Dutch have done studies in which they followed up with the kids that did get puberty suppression, who are now in their 20s or older, and they found that psychologically these people are doing great—maybe even better than the control groups that they compared them against.

TCPR: Can you tell us about the terminology we need to know while treating transgender patients?
Dr. Drescher: First, it is very difficult keeping up with the constant change in appropriate language. Terms that were perfectly appropriate just a year or two ago are no longer appropriate for a variety of reasons. One basic thing worth keeping in mind is that it’s really important to think about the pronouns and names of the people who are your patients. Ask patients directly how they want to be addressed. Be aware that some people use conventional male and female pronouns, and some people prefer “they.” I think Facebook offers about 50 different choices that one can use in terms of pronouns.

TCPR: Can you give us a practical example of how to apply pronouns?
Dr. Drescher: Sure. An easy place to make a change is on our intake forms. Under gender, you could have male, female, or other—and then “please specify.” Another example is on the inpatient unit. Let’s say there’s a transgender patient who is legally male but identifies as female. The chart has to have the legal male name on it. What should one do? I suggest writing a note at the beginning of the chart saying that the patient is legally still male but identifies as female, and going forward in the chart we will use female pronouns. It’s not rocket science.

TCPR: Are there transgender individuals who don’t want to transition? I’m thinking of people who don’t want to conform to either gender, and may view gender transitioning as conforming to binary stereotypes.
Dr. Drescher: That’s true. Another change with DSM-5 is that we now talk about the “other” gender instead of talking about genders as binary “opposites.” Genders are not necessarily opposite to each other; that’s just the conventional way it’s been conceptualized. It’s possible for people to meet diagnostic criteria for the diagnosis of gender dysphoria who are not thinking in male/female binaries, but who may be presenting themselves with some other representation of gender. Another thing to keep in mind is that not all transgender people have gender dysphoria. Many are secure and happy with their gender identity. People who identify as transgender are all different from each other. They don’t all want the same thing, and they are not all moving in the same direction. So, one of the things that is helpful in dealing with patients is to not make assumptions, to listen to their story, to develop tactful skills for questioning them about where they are in their life right now, what their goals are overall, and what their goals are in regard to gender. What are their thoughts about their gender? I do have patients who are very sensitive about being misgendered. They’ll say, “If I identify as female, I’m dressed in a female way, and you call me ‘sir,’ you are misgendering me.” Or, a more common thing is the patient who is preoccupied about whether everybody they pass on the street identifies them as the gender they consider themselves to be.

TCPR: On the last point, can you give us a specific patient example and share how you dealt with it?
Dr. Drescher: I had a patient come in complaining that people were looking at her on the street, and she felt that they were “tagging her as male.” I was very direct and said, “Look, if your level of self-esteem is going to depend on everybody getting your gender right, you are going to be in a lot of trouble. And if your self-esteem is going to depend on everyone getting your pronouns right, you’re not going to be able to withstand some of the things that will happen in life. That’s not to dismiss your hurt feelings, but to say that the reality is that you will have to develop a certain amount of resilience.”

TCPR: That really is putting it right out there, but how do you get to the point where you can speak to the patient in such a direct way?
Dr. Drescher: It’s a very important question. I think it takes a relationship where the patient feels that you understand what they are going through. That happens over time and goes back to what I said earlier about being able to talk with them and understand where they’re at while being able to listen to their story. Once they are comfortable knowing that you understand them, it’s been my experience that you can talk frankly with them about getting over being misgendered by people.

TCPR: What are some good resources for psychiatrists working with this population?
Dr. Drescher: One really good resource is the World Professional Association for Transgender Health (WPATH). They have published guidelines, including standards of care for evaluating patients prior to surgery, and those are free at wpath.org/publications/soc. I think that’s a great starting point. There are also resources available through groups such as the Association of Gay and Lesbian Psychiatrists (AGLP) at www.aglp.org. A great book is Transgender Mental Health by Eric Yarbrough, which was released last March by APA Press and has sample letters for patients seeking surgical reassignment.

TCPR: Thank you for your time, Dr. Drescher.