Access to Care Remains Problematic for Transgender Patients

Psychiatrists have an important role to play in assisting people who are transgender, and that includes helping them secure desired medical treatment and serving as an advocate in other ways as well.

About 1 in 150 adults in the United States—1.4 million—identifies as transgender, which is more than double previous estimates from about a decade ago, according to a 2016 Williams Institute report. Although transgender individuals still face tremendous stigma, the world is gradually becoming more accepting: the World Health Organization announced last month that being transgender is no longer classified as mental illness in its International Classification of Diseases, 11th Revision, but is instead classified as a sexual health condition.

Access to care remains a major issue, according to Eric Yarbrough, M.D., director of psychiatry at Callen-Lorde Community Health Center in New York City and former president of AGLP: Association of LGBTQ Psychiatrists. Adults who are transgender sometimes drive for hours to see a psychiatrist at Callen-Lorde to get a letter that attests to their gender identity or readiness for surgical interventions, he said. Such letters are usually required before individuals can receive medical interventions or change gender markers on insurance or identification cards.

Some of these patients have psychiatrists back home who are reluctant to provide the needed documentation, Yarbrough explained, perhaps out of fear of a bad outcome or a lack of experience in working with people of transgender experience. “If a person needed to have his or her gall bladder taken out, would people be questioning it?”

APA formally recognized the benefit of medical and surgical interventions for gender-variant individuals seeking to transition and advocated for removing barriers to care in a 2012 position statement. But gender-affirming treatments are often seen with a bias, said Yarbrough, who has met with 1,000 people of transgender experience to date at Callen-Lorde and is the author of Transgender Mental Health from APA Publishing. “If psychiatrists would just meet transgender people and talk with them, they would quickly align with them, and it would make a lot more sense from a clinician’s standpoint.”

Yarbrough has come to believe that psychiatrists should be moving away from the role of “gatekeeper” (that is, deciding which patients should be eligible for which gender-affirming treatments) to one of informed consent, where the psychiatrist’s role is to support patients’ autonomy, ensure their capacity for decision making, and ensure their understanding of the long-term risks and benefits.

Most clinicians have the skills to do these basic psychiatric evaluations of capacity needed to write the letters. “The majority of patients of transgender experience come into a psychiatrist’s office already knowing what they want,” he said. “Our role is to help people figure out who they are and what they might want out of life.” Top surgery for a man who is transgender, for example, is a fairly safe outpatient procedure, with minimal follow-up needed, Yarbrough pointed out. “But just having a particular body part causes them distress on a continuous and daily basis.”

“The vast majority of people who have these procedures are happy with them long term,” Yarbrough added. “But the world isn’t accepting of people who are transgender, and the surgical procedures aren’t necessarily perfected, both of which complicate matters.”

Still, only very rarely, and that is in 1 to 2 percent of cases, do patients express regret after having gender-affirming procedures, he added. One long-term study that followed individuals for an average of 14 years after changing genders found high degrees of well-being, and no participants wished they could return to their birth gender. Another found that only 2 in 162 patients who had completed hormone treatment plus gender-reassignment surgery had regrets.

Having a clinician serve as both therapist and gatekeeper can pose problems if patients withhold feelings of ambivalence about transitioning to appear to be the perfect candidate for approval of medical treatments, said Edmund G. Howe, M.D., J.D., a professor of psychiatry and a senior scientist at the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences.

Howe added, “Some patients who are seeking gender reassignment surgery can end up in a bind of ‘should I tell it like it is—or should I make it most likely that you’ll write the best recommendation?’ ” In cases like this, Howe discusses with patients whether they want their psychiatrist to step out of the dual-agency role and serve only as therapist, he said.

Most importantly, clinicians need to authentically see these individuals as the gender they feel they are, rather than as the gender they appear to be. “Using the right pronouns is important to not offend transgender persons,” he said.

He has found that the need for medical interventions for these patients varies; some individuals feel satisfied after just one treatment, such as hormone therapy, whereas others need the full array of treatments. “It is important for clinicians to be totally open to the full range of treatments that their patients might want.”

Howe is careful to refer to transgender individuals as “persons” rather than patients, because he has found that some are offended by the notion that they might have a psychiatric illness. Indeed, clinicians must weigh giving a diagnosis—typically gender dysphoria under DSM-5 for transgender individuals—that might upset and alienate patients with the need for providing a diagnosis to receive coverage for care.

Assessing the capacity of transgender individuals with other mental illnesses can be challenging. One young patient of Howe’s whose mother said he had been miserable his entire life was happy and “a different person” hours after having gender-reassignment surgery.

“I have seen persons for whom transitioning renders some of their previous diagnoses moot, although that is not always the case,” Howe said. ■

APA members may access APA’s “Guide for Working With Transgender and Gender-Nonconforming Patients” here. APA’s Position Statement on Access to Care for Transgender and Gender Variant Individuals can be accessed here.