The Consultant Psychiatrist and the Transgender Patient

Ms. S. was a transgender woman in her mid-40s who was admitted to the medical service for acute stabilization and medication management following a suicide attempt. Throughout her hospitalization, utmost care was taken to maintain her gender-affirming medication regimen and avoid negative drug interactions. The team found it relatively clear-cut to determine which options were most beneficial in treating her mood disorder. However, approaching the psychosocial aspects of her transition and gender identity was more complex. At one point while discussing the case, a member of the team asked “where” Ms. S. was in her transition and later queried, “Is she complete?” Ultimately, following inpatient psychiatric care, Ms. S. demonstrated great improvement and was discharged to the care of follow-up providers with known experience in gender-affirming practice.

As we navigate a world in which issues of diversity, equity, and inclusion are increasingly being given the attention they deserve, colleagues from other specialties turn toward psychiatrists as role models. Consultation-liaison psychiatrists are optimally poised to both advocate for patients and educate fellow physicians in providing culturally informed care, as we peer through the biopsychosocial lens. Our responsibility to patients extends beyond their physical well-being to their emotional and cultural safety in health care settings. In cases involving gender-affirming care, the consultation-liaison psychiatrist liaises with colleagues from endocrinology, plastic surgery, urology, obstetrics/gynecology, nursing, social work, speech therapy, and physical therapy, to name a few.

When patients present for care outside of the explicit context of seeking gender-affirming care, their gender identity may not be pertinent to their presentation. An overt focus on gender identity is more informally referred to as “trans broken arm syndrome,” according to Wiktionary. The most recent report of the U.S. Transgender Survey (2015) found that 23% of respondents did not see a doctor when necessary because of fear of being mistreated as a transgender person. One-third (33%) of respondents who had seen a clinician in the past year reported having at least one negative experience related to being transgender, including having to teach the clinician about transgender people to receive appropriate care (24%) and being asked invasive or unnecessary questions about being transgender not related to the reason for the visit (15%).

A systematic review in the March 2017 BMC Medical Ethics showed that health care professionals exhibit the same levels of implicit bias as the wider population. In this case example, given that there was some concern from the team that the patient’s suicide attempt might be related to her gender dysphoria or experience of minority stress, it might be appropriate to inquire about her experience of gender by employing an empathetic, cultural lens. However, the clinician in question exhibited possible unconscious biases dictating that transgender and gender-diverse (TGD) individuals have experiences along a predetermined course with an end goal prior to which they are somehow “incomplete.”

The question is an example of benevolent transphobia, according to a 2018 report in Women & Language. On the one hand, it may be a well-intentioned though maladroit attempt to query the patient’s emotional well-being related to her transition. On the other hand, whether intentional or not, it implies that the patient might be less of a person for having not completed certain procedures. Such discourse suggests a lack of understanding and stems from the need for further education and training in working with TGD individuals.

The World Professional Association for Transgender Health published “Version 8 of the Standards of Care for the Health of Transgender and Gender Diverse People” last year. These standards include a chapter on mental health, with recommendations including that “all staff use the correct name and pronouns (as provided by the patient), as well as provide access to bathroom and sleeping arrangements that are aligned with the person’s gender identity.” However, as psychiatrists, our role extends beyond this. It is critical that we do the following:

• Prioritize the TGD patient’s needs over our own curiosity.

• Communicate thoughtfully and respectfully, including when the TGD individual is not present.

• Employ cultural humility by questioning our implicit biases and educating ourselves.

• Be receptive to patient feedback.

• Educate our colleagues and advocate for our TGD patients.

• Recruit and support TGD students, trainees, and colleagues.

• Challenge structures that perpetuate health care inequalities for TGD individuals.

Coming back to the case of Ms. S., the consulting psychiatry team took the lead in educating colleagues about considerations for working with transgender patients. This case was also presented in Schwartz rounds to allow for further education and cultural sensitivity training. ■

Fiona Fonseca, M.B.B.Ch., B.A.O., M.S., is a consultation-liaison psychiatry fellow at the Mayo Clinic in Rochester, Minn.

Anna Dorsett, M.D., is a second-year resident at Wake Forest Baptist Health in Winston Salem, N.C.

James Kimball, M.D., is an associate professor of psychiatry at Atrium Health Wake Forest Baptist in Winston-Salem.