An Interview With Hansel Arroyo, M.D., on Transgender Psychiatry

Dr. Kim is a third-year resident in the Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York. Dr. Kim is also Deputy Editor of the American Journal of Psychiatry Residents’ Journal.

Dr. Kim: How did you choose to pursue a career in transgender psychiatry?

Dr. Arroyo: Working with minorities and underserved populations has always been an interest of mine.

During residency, I had the opportunity to develop free mental health services that served a part of the hospital community that is tied to Spanish Harlem. Through these programs, we created a dialectical-behavior therapy group to treat multiple mood disorders and to capture a wider range of mental health needs in this population. During my career, my interest in minority populations [has] continued and transitioned to sexual and gender minorities. During my psychosomatics fellowship, I gravitated toward people living with HIV, and after graduation I continued my work at the Institute for Advanced Medicine, which is the largest HIV clinic in New York City. At the clinic, we treated a large population of transgender patients, especially transgender women of color, who have high rates of HIV infection. Then, with nurse practitioner Zil Goldstein, Dr. Jesse Ting, and much support from the hospital leadership, we developed the Center for Transgender Medicine and Surgery.

Dr. Kim: What has been the most challenging aspect of developing this field?

Dr. Arroyo: In developing the center, like in any multidisciplinary clinic, communication between providers is key. We simply speak different languages. I’ve been in mental health services for about 8 years. Every medical field acquires a language of [its] own, especially in psychiatry: the way we refer to patients—diagnostics—the way we use titles such as "personality disorders," the way we rank the mental health needs for our patients. This can be completely different for another physician who may not be familiar with this language. In multidisciplinary clinics, you have to learn how to translate. I’m very lucky [to have] the team at the Center for Transgender Medicine and Surgery. Because we work together in the same physical space, we can communicate and clarify issues more easily. Collaborative care works when you are in the same space.

Dr. Kim: How would you describe your style as a psychiatrist?

Dr. Arroyo: Flexibility is important. You cannot work in an integrative medical-surgical clinic as you would in a solo private practice. It’s very different. In a medical clinic, patients walk in at different times; they can be late; patients may be in crisis—you have to be comfortable being interrupted by other medical providers and staff…for an emergency or question.

Dr. Kim: Can you tell us about your work?

Dr. Arroyo: My work focuses on treating the mental health needs of transgender and gender nonconforming individuals. We don’t treat "transgenderism" but rather help individuals during their transition, if they wish to do so, and we treat any comorbid psychiatric conditions.

Dr. Kim: What are guidelines provided for transitioning?

Dr. Arroyo: We follow the standards of care of WPATH [World Professional Association for Transgender Health]. For those patients interested in medical transition, the standards of care say that before initiating hormone therapy, a patient needs to be diagnosed with gender dysphoria [DSM-5] and have [the] capacity to make this decision. A psychiatric evaluation is not required but can be done at the request of the primary care doctor. For those patients interested in surgical intervention, the standards of care say that other than having the diagnosis of gender dysphoria and [the] capacity to make the decision, a psychiatric evaluation is required. For "top surgery," which is either chest masculinization surgery for trans[gender] men or chest feminization surgery for trans[gender] women, only one psychiatric evaluation is required. Two independent psychiatric evaluations are required for "bottom surgery," which can be orchiectomy or vaginoplasty for trans[gender] women and vaginectomy, metoidioplasty, or phalloplasty for trans[gender] men.

Dr. Kim: When does your clinic recommend a patient start hormone therapy?

Dr. Arroyo: Whenever the patient is ready, but we can start as early as Tanner stage 2, with puberty-blocking agents. For example, a trans[gender] woman is often very afraid and anxious about developing male secondary characteristics during puberty. It can be a very stressful experience, so at that stage, we often block the initiation of puberty and its secondary sexual characteristics. Later we can start hormone replacement therapy. Going back to the standards of care, a psychiatrist does not have to be involved in giving the green light for initiation of hormone therapy. The primary care doctor can diagnose and proceed. However, at times they will ask a psychiatrist to give a green light if there is [a] history of comorbid mental health disorders. For surgical intervention, since the risks are higher—and in the case of "bottom surgery" we are talking of a procedure that involves the loss of reproductive capabilities—we really want to make sure we mitigate any pre- and postoperative complications that the presence of an active psychiatric disorder can cause and that patients have a thorough understanding of the procedure itself.

Dr. Kim: What sort of outcome do you let patients know to expect in terms of psychological health and well-being? How do you navigate those conversations?

Dr. Arroyo: Well, we know that transgender kids who have family support do better in school and do better professionally down the road. We know that helping patients transition decreases psychological distress, depression, and anxiety. We really need to educate patients and their support network on the importance of support through this experience. We know that the rate of suicide in the transgender community is about eight times higher than the general population; the risk is around 40% (1). That’s a big number, and it’s scary. However, we know that treating patients who have gender dysphoria with hormone therapy can decrease that risk (2, 3). We also know that patients who have had surgical interventions often express high rates of surgical satisfaction.

Dr. Kim: Could you elaborate on the high suicide rate?

Dr. Arroyo: Many of these individuals have experienced extensive trauma in their lives, much discrimination, and minority stress. We know that being in a state of stress, in this case [as] a gender or sexual minority, can increase your basal cortisol level, which then predisposes you to developing depression and anxiety. There are also higher rates of mood disorders in transgender patients that can contribute to the suicide rate (1, 4).

Dr. Kim: How do you see this field moving forward?

Dr. Arroyo: There isn’t a lot of scientific literature out there in terms of transgender health. Not only propagating the knowledge we do have but also developing research programs is crucial. I think creating programs that continue to educate the upcoming generation of medical providers and creating a space for that to happen would be ideal. We can provide and share the knowledge that is available, but…we must also seek to advance the field of transgender health.