Newswise – Waltham March 7, 2024 When caring for transgender and gender diverse (TGD) individuals, psychiatrists should focus on alleviating the effects of gender minority stress with the goal of promoting resilience. according to a review published in Harvard Review of Psychiatry, Part of the Lippincott portfolio of Wolters Kluwer.

“We envision a role for psychiatry that goes beyond gatekeeping gender-affirming hormone therapies and surgery,” says Alex Keuroghlian, MD, MPH, Michele and Howard J. Kessler, chair and director of the Division of Public and Community Psychiatry at Massachusetts General Hospital Boston and colleagues. “Instead, we should invest in equitable care across the continuum of mental health needs.”

Psychiatric assessment prior to gender-affirming care

The World Professional Association for Transgender Health The 2022 guidelines recommend eliminating the practice of requiring a mental health assessment before gender-affirming medical or surgical treatment, the authors note. Patient regret and desire to transition are rare outcomes, and there is little evidence that prior psychiatric evaluation has any impact on their likelihood. A better option is for physicians providing gender-affirming care to document informed consent after discussing the benefits and potential risks of an intervention.

Key areas of proposed clinical improvement

Dr. Keuroghlian and co-authors provide practical guidance for providing responsive, high-quality psychiatric care for TGD patients. Some of the key topics they discuss are:

Dealing with psychiatric illnesses –In general, the diagnosis and treatment of psychiatric illnesses in TGD individuals are not fundamentally different from those in cisgender individuals. However, suicidal thoughts are associated, for example, with internalized transphobia, expectations of rejection and concealment of identity. When developing a comprehensive plan to treat depression in a TGD patient, it is important to consider gender minority stress.

Another example: Many TGD people suffer from chronic social rejection, which can lead to hypervigilance. This response to gender minority stress must be distinguished from the rejection sensitivity characteristic of borderline personality disorder.

Interaction of psychopharmacology and gender-affirming hormone therapy –Psychiatrists should familiarize themselves with the nuances of prescribing psychotropic drugs to TGD patients. For example, lamotrigine and estrogen may have bidirectional effects on serum levels. Therefore, it is advisable to check both drug levels when changing the dosage of either medication. Risperidone is known to cause hyperprolactinemia, which can lead to unwanted gynecomastia and subsequent gender dysphoria in transmasculine people. In these patients, it may be important to closely monitor prolactin levels. Additionally, physicians should discuss prolonged erections associated with trazodone and the decreased erectile function that often occurs with selective serotonin reuptake inhibitors. TGD patients may differently perceive these phenomena as benefits or exacerbations of gender dysphoria.

Acute psychiatric settings –Case studies have identified gender dysphoria in patients with psychosis; In these situations, gender-affirming care is often refused. However, a comprehensive clinical history may reveal gender diversity that predated the psychosis. Endorsement of gender diversity during a psychotic episode may be related to disinhibition rather than delusional thinking.

Likewise, fluctuating gender identity in a patient with suspected psychosis should not be viewed as evidence of this diagnosis. Psychiatrists should work nonjudgmentally with the patient to understand their gender identity (e.g., non-binary, genderqueer) and help resolve delusional thinking from simple uncertainty about gender identity. Continuing gender-affirming hormone therapy is recommended, particularly in acute psychological crises.

TGD people often fear being pathologized and may be dissatisfied with group therapy and psychiatric medications, Drs. Keuroghlian and colleagues stated. They also likely lack access to gender-inclusive mental health care, particularly for TGD people of color. The authors emphasize “the importance of continuing to educate physicians and staff in psychiatric facilities and approaching care in an individual, cultural and patient-centered manner.”

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read article [ The Role of Psychiatry for Transgender and Gender Diverse Adults ]

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