Transgender Patients: Considerations for Care

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CLINICAL CONVERSATIONS

According to research, transgender individuals are 4 times as likely as their cisgender peers to have a mental illness.¹ In honor of Pride Month, Psychiatric Times spoke with Adil A. Mohammed, MD, a board-certified psychiatrist in general psychiatry at Harmony United Psychiatric Care in Florida, to discuss culturally competent care strategies and tips.

Psychiatric Times (PT): What top 3 considerations should clinicians keep in mind when tending to a transgender patient?

Mohammed: 1. Misgendering. As mental health professionals, we must understand that the way we identify someone can have a significant impact on their overall mental well-being. A best practice to avoid misgendering is during the first introduction or interaction with a patient, mental health professionals should ask the patient what their pronouns are instead of making assumptions. By starting off the interaction knowing you are identifying your patient correctly and not adding to the misgendering they presumptively have faced in the past, you are starting off the relationship with a sense of trust and your patient will feel they are understood.

2. Microaggressions. Be aware of your staff members’ attitudes toward gender identity and gender expression. Any mental health professional who commits microaggressions or who expresses negative attitudes toward transgender patients will affect the overall quality of care for the patients and their families. To combat the possibility of microaggressions in this industry, I recommend mental health care facilities offer training sessions to educate staff members on misgendering, the LGBTQ+ community, and ways to identify subconscious bias and microaggressions. It is important that your staff feel like they have the resources and proper training to know how to provide the best quality of care for transgender patients.

3. Ensure you and your staff understand the transgender community and the issues that they face. As mentioned previously, understanding your patients is the most important thing you can do as a mental health professional. If there is something you do not understand about the transgender community right away, take the time to educate yourself or request in-facility training so you can give your patients the best experience possible. Ask yourself whether you fully understand how factors like stigma, prejudice, discrimination, hate crimes, and violence can affect the well-being of the transgender community.

PT: How do your recommendations change based on geography, especially in states that may be less supportive of LGBTQ+ patients?

Mohammed: Mental health professionals should educate themselves on the issues that the LGBTQ+ community are facing in their state or local communities to further understand the impact on their mental health. Since Harmony United Psychiatric Care is Florida based, we know that transgender patients in our community are probably being impacted heavily by the hostility and legislation being signed against their rights. Each state will have its unique issues that this community faces, but the considerations for care always remain the same.

If we take a look at Florida, the state ranks 46th in the nation in terms of its accessibility for residents to access mental health care.² This lack of local resources could lead to serious concerns for residents who have severe depression or suicidal thoughts, making it especially concerning for the local transgender community, who are already 4 times as likely to have a mental illness. With this lack of resources for Florida residents and the local LGBTQ+ community in mind, Harmony United Psychiatric Care has adopted the mission to address this critical problem by promising quicker and more efficient care through its offering of new patient appointments as soon as the same or the next day. We also offer telehealth and teletherapy appointments for those who live in rural parts of the state who are in need of mental health resources.

The easy access we offer our residents is game-changing in a state with such little access to mental health care resources, so we like to think that our location has encouraged us to offer open arms to anyone who needs help in our state, especially the transgender community, during these challenging times.

PT: Debates on bathroom choices to sports participation for transgender individuals are not uncommon. How do these discussions impact clinical care?

Mohammed: There have been ongoing conversations around the restrictions of the local transgender community, as seen most recently with Florida Governor Ron DeSantis’ bill requiring transgender individuals to use public bathrooms that correspond with their sex at birth.³ Local LGBTQ+ advocates have reported that transgender children and teens are scared for their health and safety, causing them to avoid public restrooms altogether.⁴ The feeling of being scared for your health and safety on a sometimes-daily basis could definitely lead someone in the transgender community to develop a mental illness, make a preexisting mental illness harder to cope with, or create an extreme environment of stress for those individuals.

Imagining a child or teen walking into school in the state of Florida and not feeling comfortable using the restroom all day long is saddening. These are the types of issues that mental health professionals should stay up to date with so they can fully understand what a transgender patient might be struggling with behind the scenes, which will ultimately impact a professional’s plan of action when treating these individuals.

PT: How has working with transgender patients changed how you practice? What resulting clinical pearls can you share?

Mohammed: I would recommend the following tips:

• We should not assume to know a patient’s gender identity by how they look or speak.
• We should not ask about gender identity or genital status unless it is directly related to care, and if it is, then we should explain why we are asking.
• We should use the name and pronouns of the patient’s preference.
• We should use gender-neutral language such as “partner” or “relationship status.”
• We should be open and nonjudgmental.
• We should be aware of misconceptions, bias, and stereotypes that could interfere with effective communication.
• We should document our care in the patient’s health record, including patient pronoun preference.
• We should obtain permission before performing a sexual health examination and conduct such an exam only if medically indicated.

PT: For those looking to learn more, can you recommend any particular resources?

Mohammed: For any clinicians out there who are not implementing education and training on the LGBTQ+ community, I strongly suggest you start. It is vital to know your team is on the same page when it comes to providing care for these individuals, how to combat and recognize any implicit biases, and what issues this community is facing that could impact their plan of treatment and mental illness.

A great way to do this could be to ask an educator on the LGBTQ+ community to come speak at your facility and provide background and create a better understanding of this community. This will also help your staff feel comfortable when speaking about pronouns and ensuring they do not misgender your patients.

Additionally, I recommend clinicians offer a cadence of training courses for their faculty, whether that be yearly or monthly, to give them the opportunity to continue their education and training. Some clinicians might not feel as equipped to help transgender patients to the best of their abilities and might be too afraid to speak up, so offering training courses or setting up trainings with educators from the LGBTQ+ community could be a very helpful offering for your facility.

As far as resources go, the American Psychological Association offers a complete list of resources for practitioners and clinicians.⁵

PT: Do you have any concluding thoughts to share with Psychiatric Times readers?

Mohammed: In my opinion, we should speak with transgender patients the same way we would with any other patients. However, we must keep in mind the previously mentioned tips.

Dr Mohammed is a board-certified psychiatrist in general psychiatry at Harmony United Psychiatric Care in Florida.

References

1. Wanta JW, Niforatos JD, Durbak E, et al. Mental health diagnoses among transgender patients in the clinical setting: an all-payer electronic health record study. Transgend Health. 2019;4(1):313-315.

2. Bolden L. Less than half of people in Florida with mental illness don’t get treatment. ClickOrlando. February 24, 2023. Accessed November 16, 2023. https://www.clickorlando.com/news/local/2023/02/24/less-than-half-of-people-in-florida-with-mental-illness-dont-get-treatment/

3. Saunders J. GOP leaders, medical groups clash in Florida restrictions on transgender people. Action News Jax. October 16, 2023. Accessed November 16, 2023. https://www.actionnewsjax.com/news/local/gop-leaders-medical-groups-clash-florida-restrictions-transgender-people/7ZJZUKOIWFFK5KC2CAFFXGRCEU/

4. Walker F, Cimini K, Goñi-Lessan A. ‘Felt like prey’: bathrooms more unsafe under new Florida law, trans people say. Tallahassee Democrat. October 18, 2023. Accessed November 16, 2023. https://www.tallahassee.com/story/news/local/state/2023/10/18/florida-bathroom-bill-causing-problems-beyond-restroom-for-trans-kids-education-school-transgender/70994247007/#

5. LGBT resources for practitioners. American Psychological Association. 2009. Accessed November 16, 2023. https://www.apa.org/pi/lgbt/resources/practitioner