Psychiatrists Need to Prepare to Care for Gender-Variant Patients

The concept of gender, or what people generally think of as the state of being male or female, is something that is so deeply engrained in our culture that attempts to even bend it are met with hostility from individuals and groups, both political and religious. Given our society’s appreciation of individual freedom, it has never made sense to me that the presentation of someone’s gender outside the expected upsets so many.

The number of trans-identified individuals seeking care for gender-affirming services has increased dramatically over the past few years. This could be due in part to the depathologizing language change from gender identity disorder to gender dysphoria in DSM-5. This change communicated a shift in psychiatric thinking regarding gender diversity, which provided a metaphorical welcome sign to those who previously felt uncomfortable or unsafe seeking psychiatric care. The increase in gender-diverse people seeking services could also be due to insurance coverage of gender-affirming treatments such as hormone therapy and surgical procedures.

As more transgender and gender-nonconforming patients are coming out and making new patient demands, the psychiatric community must be prepared to care for more gender-diverse individuals. The first step in the process includes examining how we think about gender.

I work at an LGBTQ clinic in New York City, and dealing with the many identities on the gender spectrum is a regular part of my work day. The idea that “male” and “female” are not a dichotomy but can exist simultaneously or not at all is part of an assumed position when working at a place like Callen-Lorde. When I speak at schools, clinics, and hospitals, it is generally about LGBTQ mental health and more recently about transgender mental health. Part of my introduction to the topic is discussing the gender spectrum, and I ask clinicians to think about what parts of their presentation are typically masculine and feminine. Surprisingly, mental health professionals—those who are thought to be the most in tune with their ideas and emotion—are sometimes defensive about the notion that their gender might be more complicated than the single identifier onto which they have held so closely since childhood.

It is good practice for all psychiatrists to be aware of their own gender and to examine the spectrum that exists within their own identity. When psychiatrists are open to exploring their own gender and gender expression, it is easier for them to approach gender-diverse patients as individuals and provide the best care. Letting go of the conventional definitions of masculinity and femininity is the first step to moving past the old gender dichotomy. Being self-aware will keep in check our own gender stereotypes and help us pay attention to the automatic assumptions that influence our daily thinking.

What is considered to be masculine and feminine behavior, attitudes, and fashion are cultural stereotypes that have been engrained in us from an early age. While some stereotypes might have biological roots, the majority are probably societal inventions. With the emergence of hormone and surgical treatment options for gender dysphoria, we are in a unique place to examine and deconstruct some of the core concepts of what makes up gender.

Through supervising other clinicians who work with individuals with gender dysphoria and exploring my own experience, I know that there are so many automatic reactions, thoughts, and ideas that require significant additional introspection. It is best that we start having conversations about them to free us up to provide sensitive and quality care. And as we do so, we will likely learn just as much about our changing society and our culture as about ourselves. ■