Hansel Arroyo, MD. Assistant professor of psychiatry, Icahn School of Medicine at Mount Sinai. New York, NY.
Dr. Arroyo has no financial relationships with companies related to this material.
CHPR: Dr. Arroyo, please tell us about yourself and your background.
Dr. Arroyo: After residency, I completed a consultation-liaison fellowship where I specialized in HIV psychiatry and worked mostly with LGBT patients. For the last six years, I have been director for the Center for Transgender Medicine and Surgery at Mount Sinai, where most of our patients are either trans, genderqueer, or gender expansive.
CHPR: Can you review the meanings of gender expansive, genderqueer, and any other terms relevant to this patient population?
Dr. Arroyo: Sure. The language is constantly changing. “Transgender” refers to an incongruence between the person’s sex recorded at birth and their gender. The term “cisgender” means that the person’s sex recorded at birth and gender are aligned. Terms like “gender nonbinary” and “gender nonconforming” imply that the individual doesn’t subscribe to the binary polarization of masculine/feminine. “Gender expansive” is a newer and more inclusive term. “Genderqueer” is another relatively new term. A person who says they’re genderqueer is saying, “I don’t subscribe to the binary.” Queerness can also be used to describe sexual attraction—whom a person is attracted to physically, spiritually, and emotionally—and includes gay, lesbian, bisexual, pansexual, and asexual individuals.
CHPR: Have there been any other changes in the terminology of late?
Dr. Arroyo: A recent change is “sex recorded at birth” versus “sex assigned at birth.” We make a distinction that the sex at birth is simply what’s recorded by the physician after examining the baby’s genitalia, but it’s not the “assigned” sex as that may change based on how children identify or view themselves as they get older. Another important term is “gender expression,” which is how one chooses to express their gender. This may or may not be congruent with either their sex recorded at birth or their gender identity (Editor’s note: See “Understanding Sexuality and Gender” figure). For example, you may identify as female, but want to express yourself in more of a masculine way. Some trans women express masculine qualities while other trans women express more feminine qualities. It’s important to practice not putting individuals into our own preconceived boxes.
CHPR: Can you give us an overview of the mental health needs of transgender and gender-nonconforming patients?
Dr. Arroyo: Sure. The US Transgender Survey showed that trans patients have higher rates of self-reported psychological distress and less access to mental health services. The National Center for Transgender Equality released this report in 2015 and it’s the largest survey of trans people’s experiences in the US, including their physical and mental health needs (www.tinyurl.com/3cvxjwa6). Several studies have shown that this population experiences higher rates of depression, anxiety, and substance use disorders compared with the general population (Dhejne C et al, Int Rev Psychiatry 2016;28(1):44–57).
CHPR: Is treating transgender patients different from treating other patients who suffer from depression and anxiety?
Dr. Arroyo: Treating transgender patients with depression or anxiety is not inherently different from treating other patients, but the mental health provider must have literacy and competency in the needs specific to transgender people. For example, transgender patients are more likely to have struggled with discrimination, rejection, or abuse. Thus, to better frame the treatment plan, the provider should be familiar with caring for patients with trauma and minority stress, and they should be familiar with issues of intersectionality. This last point requires an understanding that each person’s experiences of discrimination are unique and involve overlapping categorizations including race, gender, and social class.
CHPR: Can you explain the meaning of the term “gender-affirming care”?
Dr. Arroyo: Gender-affirming care refers to a philosophy of care that respects a patient’s gender identity and doesn’t impose a “one size fits all” approach. Gender-affirming treatments come in many forms, and no one trans experience is universal. Some trans people transition socially, while others choose to transition chemically or surgically. But not every trans person sees themselves in a binary way, needing to be surgically feminine or surgically masculine. In all cases, it’s important to provide patient-centered gender-affirming care.
CHPR: Can you tell us about the types of gender-affirming treatments?
Dr. Arroyo: Sure. There are two main treatments: hormone replacement therapy (HRT) and surgery. HRT decreases depression, anxiety, and PTSD; the only symptom that HRT doesn’t quite help is self-perceptions of one’s body (White Hughto JM et al, Transgend Health 2016;1(1):21–31). This makes sense—while hormones change patients phenotypically, there are limitations to the degree of physical change, so often people will opt for surgical interventions. I should point out, though, that the data come from uncontrolled cohort studies. The studies behind surgeries show a decrease in gender dysphoria and a high rate of satisfaction: around 95%–100% satisfaction from surgical outcomes (van de Grift TC et al, J Sex Marital Ther 2018;44(2):138–148). Recent studies have also reported an association between gender-affirming surgeries and improved mental health outcomes (Almazan AN and Keuroghlian AS, JAMA Surg 2021;156(7):611–618). And research in veterans has found that the combination of HRT plus both chest and genital surgery results in lower rates of suicidality when compared to no intervention, HRT alone, or HRT plus only chest or genital surgery (Tucker RP et al, Psychol Med 2018;48(14):2329–2336).
CHPR: How do mental health outcomes compare following HRT vs surgical interventions?
Dr. Arroyo: It’s hard to compare surgical interventions with hormonal treatments because in the US, insurance requires that patients be psychiatrically cleared before surgery. For example, in our clinic we don’t clear patients for surgery if they have active symptoms of depression. Since everybody who has surgery has already been deemed to be psychiatrically stable, it’s hard to measure a before and after effect of the surgery.
CHPR: But a patient’s depression might be related to their gender dysphoria, right? Yet they can’t get the surgery that will help address the gender dysphoria because of their depression.
Dr. Arroyo: Right, so it’s important to try to distinguish depression due to those reasons vs an endogenous major depressive episode. But ultimately, the important thing is the patient’s well-being. The fields of transplant and bariatric surgery follow a similar practice where patients are psychiatrically cleared prior to surgery, as this improves surgical outcomes. For example, a clinically depressed patient might fail to attend postop appointments or practice proper wound care.
CHPR: Are there other measures besides mood that can be used to compare mental health outcomes following HRT vs surgery?
Dr. Arroyo: We also look at body satisfaction or decrease in gender dysphoria, and these measures show that the interventions result in comparable mental health outcomes (van de Grift TC et al, Psychosom Med 2017;79(7):815–823).
CHPR: How available are gender-affirming treatments?
Dr. Arroyo: They are now widely available for those who are insured. In 2014, Medicare reversed the ban on transgender services. Most insurance policies cover HRT, and at least some surgical interventions, like chest feminization or masculinization surgery, and “bottom surgeries” or genital surgeries including vaginoplasty, orchiectomy, metoidioplasty, and phalloplasty, are considered medically necessary (Editor’s note: See “Common Gender-Affirming Terminology” table). Over the last few years, we’ve also seen increases in coverage for facial feminization and masculinization surgeries, which historically were considered only cosmetic. Other surgeries like body contouring aren’t covered by insurance yet. Some insurers will cover electrolysis or laser hair removal on the face or genital area, or Botox and fillers, but many don’t.
CHPR: When trans patients are admitted to psych inpatient units and they’re on hormonal treatments, some clinicians can be hesitant about continuing these hormones since they’re not used to prescribing them. Are there adverse consequences to suddenly stopping these supplemental hormones?
Dr. Arroyo: That’s a common consultation question from emergency departments and inpatient units, where the doctors ask, “Do we continue the hormone treatment?” And the answer is “yes,” unless there’s a medical concern, like the risk of coagulation for someone on estrogen. Historically, it was believed that testosterone for trans men caused manic-like symptoms. Those concerns came from the bodybuilding literature where the testosterone levels were supratherapeutic. In those patients, you can see irritability, mood lability, anger, and agitation that might resemble a manic episode. But for trans patients, testosterone levels are usually monitored to be within the normal ranges of their cis counterparts, so there is no need to worry that manic-like symptoms are the result of the hormones. My recommendation is to check the patient’s testosterone levels and make sure that they are within the appropriate age range for their cisgender counterparts. Stopping testosterone abruptly can result in increased gender dysphoria and can create low energy, low mood, irritability, and low libido.
CHPR: What about estrogen?
Dr. Arroyo: The two main feminizing medications are estrogen and spironolactone. For trans women, their estrogen levels should be within the normal range, compared to their cis female counterparts of the same age. In general, you don’t have to worry that estrogen will cause mood instability. On the contrary, often we see patients who are depressed, and their primary care provider sends them to us asking, “Can you start her on an SSRI?” We evaluate them and we often instead recommend starting HRT first. You’d be surprised how often the mood symptoms lift, partly because they were so interconnected with the gender dysphoria. And if you stop the hormonal medication on the inpatient unit, the patient might then have a relapse of or an increase in depressive symptoms.
CHPR: What hormone levels do you measure, specifically?
Dr. Arroyo: We check total and free testosterone. Depending on age, normal testosterone levels range from 200–1000 ng/dL, and free testosterone levels range from 40–245 pg/mL. For estrogen, we measure estradiol, and normal levels range from 30–400 pg/mL for premenopausal women and 0–30 pg/mL for postmenopausal women. These ranges are based on cis individuals. We use cis counterparts to determine the appropriate ranges for trans people, although there is quite a bit of debate on the appropriateness of doing so.
CHPR: Are there any side effects we should watch for when patients are on hormonal supplements?
Dr. Arroyo: Primarily, the concern is for thromboembolic events in patients on estrogen, especially for patients who smoke as they are at higher risk. Two- to four-fold increases in myocardial infarction have been documented in transgender men, although there are probably many reasons for this higher rate besides hormone exposure, like social stressors and health disparities (Alzahrani T et al, Circ Cardiovasc Qual Outcomes 2019;12(4):e005597).
“The treatment of transgender patients with depression or anxiety is not inherently different from the treatment of any other patient, but the mental health provider must have competency in the needs specific to transgender folks. The provider should be familiar with caring for patients with trauma and minority stress that will better frame the treatment plan.” Hansel Arroyo, MD
CHPR: Do you have any concerns that the hormones will interact with the patient’s medications?
Dr. Arroyo: Only with certain medications. If somebody is on spironolactone and you start lithium, you must closely monitor the lithium levels because spironolactone reduces the renal clearance of lithium and can lead to lithium toxicity. Carbamazepine and oxcarbazepine can reduce estrogen levels, so if a trans woman is on these medications, you must monitor the estrogen levels. With divalproex (Depakote), you need to be mindful of polycystic ovary syndrome (PCOS) in trans men whose ovaries and reproductive system are intact. Also, divalproex-induced alopecia may produce psychological consequences if the individual is already experiencing testosterone-induced hair loss.
CHPR: Are there any other hormonal issues we should consider?
Dr. Arroyo: It’s important to monitor for antipsychotic-induced hyperprolactinemia, especially in trans men. If they start developing breast tissue or milky nipple discharge, those side effects can exacerbate gender dysphoria (Editor’s note: See CHPR Jul/Aug/Sept 2021 for more on antipsychotic-induced hyperprolactinemia).
CHPR: When a trans person is admitted to an inpatient unit, how do you make decisions about what room to place them into? I’ve encountered situations where a trans patient wants to be in a room with cis counterparts, but we’ve had some concerns—for example, a trans man who retains prominent feminine features is at risk of being sexually harassed in a room with cis men.
Dr. Arroyo: First we ask about the patient’s preferences and see if we can accommodate them. If a patient wants a single room, we try to accommodate that request. On the medical side, it’s easier to give them a private room. In our psychiatry unit, we have some two-patient rooms that we can convert into a single room. I had a case involving an incarcerated trans man who wanted to be with other cis men. In the prison system, we thought that would be unwise as the patient would be at risk of being assaulted. We wanted to honor the patient’s request, but we did not feel comfortable putting them at that risk. In the inpatient setting, the risk of assault or violence is not that extreme, but you still need to take potential risks into account and have a dialogue with the patient about the options and risks.
CHPR: So, it’s best to make these decisions on a case-by-case basis, trying to accommodate patients’ wishes as much as possible while keeping safety issues in mind.
Dr. Arroyo: Right.
CHPR: Have you seen a greater openness among clinicians with regard to accepting gender-nonconforming patients?
Dr. Arroyo: My sense is that yes, there’s greater acceptance, but we don’t have a lot of data on that question. However, we have made clear progress in terms of more individuals feeling comfortable identifying as genderqueer, gender expansive, and trans. The more society learns about gender and gender expression, the less people will be bound to the traditional male/female binary. More adolescents are identifying as genderqueer or gender expansive and leaving the binary terms of male/female behind. And whether they are trans or not, they are increasingly turning away from the idea of being anchored by those two poles.
CHPR: Thank you for your time, Dr. Arroyo.
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