Transgender Patient Care on the Inpatient Psychiatric Unit

Case Vignette

“Juliette” is a 40-year-old transgender woman with bipolar disorder admitted to the inpatient psychiatric unit involuntarily following an interrupted suicide attempt. Juliette uses female pronouns, has been taking estrogen and spironolactone for several years, and is recognized by her family and coworkers as female but dresses androgynously. Her first episode of depression occurred before coming out as transgender, and she has continued to have manic and depressive episodes while living happily as a woman. During a disagreement over access to her belongings, staff on the unit inadvertently refer to Juliette as “he,” provoking her to anger. During attempted verbal de-escalation, male pronouns are repeatedly used, further agitating Juliette and resulting in restraints and injection medication.

Creating a Therapeutic Environment

Special consideration for transgender patients should start prior to their arrival to the inpatient psychiatric unit. Many institutions room transgender patients with patients of the same assigned (by society to the individual at birth), but not affirmed (to which the individual has transitioned or is in the process of transitioning), gender. This can feel invalidating, traumatizing, and discriminatory to the patient, as well as confusing to the roommate. Patients should share a room with others of the same affirmed gender, and if this is not feasible, a private room should be assigned. Staff should be aware of the patient’s desired name and pronouns, especially when these do not align with the medical record. In general, withholding an outpatient hormone regimen will acutely worsen dysphoria for patients. Similarly, affirming devices, such as chest binders or breast prostheses, should be permitted unless they pose a significant safety concern.

Initial Interview

Given its relatedness to the patient’s core identity and the need for mental health providers to have a full developmental history, a basic understanding of the patient’s gender journey is a crucial part of the psychiatric interview for all transgender patients (see Table 1). Questions about their relationships and response to their identity in their social environment can assess for risk and protective factors, especially since the absence of support or exposure to discrimination and violence increases the risk for psychological distress (1–3). When patients volunteer information, clarifying questions about their medical transition process should be asked. It is critical to frame such questions in a manner that will enable the patient to understand the rationale. In gathering this information, it is important to remember that it is never appropriate to ask patients directly about their genitals. Additionally, some individuals undergo social transitioning (usually involving dressing in a stereotypical masculine or feminine fashion) without ever undergoing medical transitioning via either hormones or surgery, and thus it is important to phrase questions in a manner that does not assume the patient desires further medical intervention. At the end of the interview, asking patients whether there is anything that can be done to make their stay on the unit more comfortable can open the discussion to addressing any missed issues.

Follow-Up Questions and Issues

Throughout the hospitalization, it is important to follow up on how the patient’s gender identity has been affirmed on the unit. When misgendering occurs, whether by use of an incorrect name or pronoun or disparaging remarks, acknowledge this mistake and facilitate an apology. Afterward, every effort should be made to avoid repeating the mistake and to focus on the therapeutic alliance and achievement of treatment goals.

Implications of Hormonal Therapy

There are many questions regarding the long-term impact of hormonal therapy for medical transitioning. However, given its comparatively recent arrival in the medical field, knowledge of this subject is limited. For patients with serious mental illness and coincidental gender variance, it is important to consider the patient’s psychiatric course prior to hormone therapy and whether something else might be driving the psychiatric presentation before concluding that the hormones are responsible for decompensation. Based on the available research data, the World Professional Association for Transgender Health has recognized a “possible increased risk” of manic and psychotic symptoms that “appears to be associated with higher doses or supraphysiologic blood levels of testosterone” (4). To date, there are no data supporting the role of estrogen in psychiatric decompensation (4). Further research needs to be conducted on the natural history of psychiatric symptoms surrounding the initiation of hormone therapy before conclusions can be drawn regarding its impact on serious mental illness.

Discussion

Lesbian, gay, bisexual, and transgender (LGBT) patients have consistently been identified to have health risks and outcomes that are distinctly different from those of non-LGBT patients (5). Relative to cisgender people, whose sex assigned at birth aligns with their gender identity, transgender individuals, whose gender identity does not align with their assigned sex, have higher rates of tobacco use, HIV infection, and, increasingly, behavioral health concerns (6). Although transgender people are not more likely to have mental illnesses, given that the rate of suicidal ideation and attempt in this population is nine times that of the overall population (7), it is imperative that behavioral health providers be skilled in supporting and treating transgender individuals in the acute setting. Future avenues of research might include evaluation of the impact of specific affirming interventions on transgender patient perceptions of psychiatric hospital stays in the short- and long-term, as well as rates of engagement and re-engagement with behavioral health care by these patients as a function of such interventions.

Key Points/Clinical Pearls