Gender Identity and Psychiatric Ethics

Over the last century, there have been a small but growing number of people whose gender identity does not conform to society’s expectations. In 2015, Caitlyn Jenner’s coming out as a transgender woman drew extensive media attention to this issue. In high schools and colleges around the country, youth who previously felt uncomfortable with their assigned genders now have a vocabulary with which to describe their experiences. If you have not yet encountered a trans individual in your practice, chances are you will.

Section 1 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states, “A physician shall be dedicated to providing competent medical care with compassion and respect for human dignity and rights.” Section 1, Article 2, elaborates, “A psychiatrist should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation.” This annotation was written before gender identity was in our collective awareness, but one should accord people with nontraditional gender identities the same respect and dignity as everyone else.

Trans people have been recognized in other cultures; for example, Two-Spirited individuals in some Native American tribes were considered a third gender and were revered.

Trans people have rarely been acknowledged in the United States until recent decades. Especially in the last five years, new vocabulary has helped people think in a nonbinary way about gender identity. Transgender—or more commonly, trans—can be used for any individual whose gender identity differs from the sex assigned to him or her at birth; genderqueer or nonbinary may be used by individuals who identify neither as male nor female; and bigender describes individuals whose identity includes both genders. Because this vocabulary is still developing, people use these words differently depending on many variables.

Media coverage of trans people is focused primarily on individuals who have transitioned to a sex not assigned at birth, usually including medical intervention such as hormones and sex reassignment surgery. This has increased public awareness of the internal experience of trans individuals, but it continues the cultural focus on a binary, either-male-or-female gender identity. For individuals who feel their gender is somewhere in between those two poles, or something else altogether, the binary view of gender is alienating.

People on the leading edge of cultural transformations are targets for those who fear change. The 2008 National Transgender Discrimination Survey found that trans individuals are more likely to experience various forms of harassment and physical assault. That study also found that trans individuals are more likely to forgo health care treatment for fear of discrimination.

In 2015, a prominent psychiatrist from a leading U.S. health care institution declared that believing oneself to be transgender is a mental illness. This not only invalidates the experience of approximately 700,000 Americans, it discourages trans people from seeking help for the stress that accompanies discernment of one’s true gender identity, as well as the anxiety, depression, and posttraumatic stress disorder that may result from rejection by family and friends, physical assault, and repeated discrimination.

Just as psychiatrists must be aware of the reality of “otherness” if we want to provide effective treatment to people who are from different racial, ethnic, and religious backgrounds, so is it necessary if we want to connect with trans individuals. First steps toward this awareness include asking the person, “What pronouns do you use?” Rather than the binary “he, him, his” or “she, her, hers,” some people prefer the nongendered “they, them, theirs” or neopronouns such as “ne, nem, nirs” and “ze, zir, zirs.” It takes a little getting used to, but using a person’s preferred pronouns conveys respect for their identity.

Because so many trans individuals are reluctant to disclose their gender identity to family for fear of a rejecting or even violent reaction, it is crucial for child and adolescent psychiatrists to ask, “How shall I refer to you when/if speaking to family?” Section 4, Article 1, of the Principles instructs us, “Because of the sensitive and private nature of the information with which the psychiatrist deals, he or she must be circumspect in the information that he or she chooses to disclose to others about a patient. The welfare of the patient must be a continuing consideration.”

An additional step toward understanding is to not assume that surgery or hormones are desired. Trans identity concerns personal identity, not just physical attributes. Although some trans individuals feel strongly that they are the opposite sex from the one assigned at birth and may want to transition to the other sex, not all trans people have that experience.

It is important to meet patients where they are at; to do so effectively, we must learn to understand their experiences. Our profession requires lifelong learning; understanding emerging populations and cultural change is as important as learning about the latest psychopharmacologic advances. There are abundant web-based resources for further education. These include the National Center for Transgender Equality) and PFLAG. ■

APA’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry and Opinions of the Ethics Committee on the Principles of Medical Ethics can be accessed here.