Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse

SPECIAL REPORT: PSYCHOEDUCATION

The data is clear: We should expect an increasing number of transgender and gender diverse (TGD) youth presenting to our practices over the coming years.¹ We must ask ourselves: Are we prepared to treat these patients and their families with the most affirming, evidence-based treatment available?²

Case Example

For discussion purposes, consider a prototypical case of “Bar,” an 11-year-old child who presents to your office accompanied by his parents. Bar was assigned female at birth but recently began identifying with “he/him” pronouns; he is scared to face impending puberty. Bar’s father informs you that he is afraid Bar will be “bullied for being gay.”

Supporting the Patient and Their Family

Recent qualitative studies suggest that the caregivers’ response and adjustment to their TGD child’s identity development is critical to the child’s mental health.³ An integrative family therapy approach should affirm and support the TGD child in an equal partnership between the caregivers and the child.⁴ Addressing attunement and attachment is important for the family system, as there is likely longstanding intergenerational trauma from adoption of rigid, binary gender norms.⁵ Families should prioritize building psychosocial support for, and affirming the gender identity of, the TGD child, rather than focus on worries like “Is this my fault?” “What went wrong?” or “Is this just a phase?” The family may express grief due to the loss of an expected future they associated with the assigned sex of a transitioning child.⁶

Distress tolerance and interpersonal relationship dynamics can be tested during a gender transition⁷; as a result, many with gender dysphoria may be misdiagnosed with personality disorders.⁸ Dialectical behavioral therapy is a good therapeutic option for these patients.⁹ It is important that group therapy options provide affirming environments for transgender group members. This includes the facilitator’s role modeling of appropriate usage of pronouns and chosen names during therapy sessions.

Disclosing a shared identity with a patient can aid the therapeutic alliance by displaying understanding and empathy for the patient’s experience, which can facilitate trust and reciprocity.^10,11 It is vital that providers reflect on whether self-disclosure is being done with the intent of improving patient care, and peer supervision around this can be of value.

Psychiatrists should model inclusive environments to their TGD patients within their offices and clinical spaces.¹² Patients and their families should feel safe to give feedback to the psychiatrist when they fail to produce an affirming patient experience.² In these situations, the administrative response should be transparent and timely, and it should address the root cause of the issue. Psychiatrists should collaborate and advocate with the family and other community and mental health professionals, such as school psychologists and counselors, to create affirming environments within the child’s home and school life.¹³ It is imperative that work with TGD patients involves ongoing feedback and participation from affected community members throughout the learning and healing process.¹⁴

To create a more affirming environment for a TGD child, psychiatrists should collaborate with the family, school, and community. For example, using noninvasive and empowering language can be a great first step in establishing not only a good environment, but also a therapeutic alliance. See Table 1 for more information, and the Sidebar.

Psychiatric Terminology: Is the Field Doing Enough?

Gender Dysphoria and Its Significance in the TGD Community

Gender dysphoria is a term that originated within psychiatry. The DSM-5-TR defines gender dysphoria as “the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” Gender euphoria is an accepted term used in the TGD community that recently entered the peer-reviewed literature.¹⁵ It is defined as a “joyful feeling of rightness” and the “powerfully positive emotions” that comes from one’s gender. See Figure 1 for more details on gender dysphoria and euphoria.

Gender dysphoria is caused by repeated exposure to gender-nonaffirming environments, which can result in higher rates of depression, anxiety, trauma and stress disorders, rumination, somatization, and suicidality in TGD individuals.^16-21 The mismatch between a person’s self-identified gender and invalidating environments can occur within multiple domains, including online, home, school, athletic, employment, carceral, and health care settings.^22-28 Access to affirming environments and health care improves mental health outcomes^28-30; on the other hand, nonaffirming environments and barriers to health care increase disparities for TGD individuals.^31,32 Due to recent attempts to criminalize evidence-based affirming health care for TGD individuals, psychiatrists should expect to see an increase in patients presenting with gender dysphoria in the near future.³³

The Gender Minority Stress and Resilience Theory

The Gender Minority Stress and Resilience Theory describes the disparate impact of risk and protective factors on the experience of internalized (proximal) and external (distal) oppression in TGD communities.³⁴ These stress and resilience factors combine with other forms of social identity–based discrimination, such as racism and socioeconomic disadvantage. Taken together, this intersectionality is responsible for the structural pathways leading to systemic health care inequities experienced by TGD community members (ie, social determinants of health).³⁵ Figure 2 provides more details on minority stress and resilience.

Minority stress models have been used to explain the increased risk for biological, psychological, and social health disparities observed in TGD communities. These biological factors include increased rates of cardiovascular disease and cancer-related outcomes, whereas psychological outcomes of minority stress include depression and suicidality.^36-38 Among the TGD community, social disparities and structural disadvantages have been noted in increased rates of incarceration, housing instability, underinsurance, and risk behaviors, such as substance misuse as a negative coping mechanism.^27,39-41

Figure 2  expands on this topic and gives examples of resilience, or protective factors, that moderate the effect of minority stress.⁴² Resilience factors include methods to create systemic and structural changes that increase the psychosocial support and affirming environments available to TGD individuals.⁴³ Additionally, TGD individuals can learn skills such as community building, advocacy, role modeling, and other expressions of pride, self-worth, and self-acceptance.

Conclusion of Case Example

You diagnose Barr with gender dysphoria and provide supportive psychotherapy throughout the social transition process. You present Barr with information regarding his local community center, where Barr becomes active in peer support and social activities. You provide educational resources to Barr’s parents, who join their local PFLAG (Parents, Families, and Friends of Lesbians and Gays) chapter to speak with other parents of TGD children. You discuss the changes in pronouns with Barr’s school psychologist and work with school administration to help develop strategies for Barr to express his gender authentically within the school’s policies.

After a year of treatment, although Barr feels more confident in his masculine gender expression, he reports ongoing depression due to expected changes with puberty. As a result, you refer Barr and his parents to a gender-affirming endocrinologist to discuss options regarding potential puberty suppression and timing.

Concluding Thoughts

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. This includes the use of sensitive and inclusive language and assisting the field in adapting to ongoing evolution of community standards of care. Similarly, it is important to integrate transition and resocialization efforts with the patient’s family, community centers, and school professionals. Table 2 provides a list of potential resources to help in this endeavor. Together, we can work to provide affirmative and evidence-based care for all youth, whether or not they identify within the gender binary.