Gender-affirming Treatment Research Articles

Accuracy of psychometric tools in the assessment of personality in adolescents and adults requesting gender-affirming treatments: A systematic review

BackgroundThe assessment and screening for personality disorders in individuals requesting gender affirming treatments may be an important aspect of predicting medical and surgical outcomes for this population, but there is no consensus on how best to do so. AimsTo review the diagnostic accuracy of psychometric tools used for the assessment of personality disorders in those requesting gender affirming treatments. MethodA systematic review: Prospero CRD42017078783 [1]. ResultsMany studies have focussed on the assessment of personality disorders in this population, but since 1979, only two have used an index and reference test. ConclusionThere are no agreed reference standards for this population and psychometric tools continue to be scored on reference data from the cisgender (not transgender) population. We need robust evidence on this issue, as individuals may be denied access to gender affirming treatments based on psychometric tools without established reliability in this population.

Provider Practices and Perspectives regarding Collection and Documentation of Gender Identity

ABSTRACT Recent recommendations to include patient sexual orientation (SO) and gender identity (GI) in the electronic health record (EHR) aim to improve clinical care and address health disparities among sexual and gender minority patients. Collection and documentation of GI may be complex due to multiple clinically relevant components. This study explored provider practices in collecting and documenting GI across multiple specialties. Qualitative interviews with 25 healthcare providers were transcribed verbatim, and thematic analysis and principles of grounded theory were used to analyze the data. Without a protocol and absent dedicated locations in the EHR for collecting and documenting patient GI, provider practices were inconsistent and highlighted challenges for communication across clinical staff. Providers noted that patients’ disclosure of GI was typically unprompted, or was presumed through disclosure of gender affirming treatments. Findings indicate the need for provider training and appropriate EHR fields to support GI collection and documentation.

Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status.

Purpose: This study examines trends in Medicare beneficiaries' mental health care use from 2009 to 2014 by gender minority and disability status. Methods: Using 2009 to 2014 Medicare claims, we modeled mental health care use (outpatient mental health care, inpatient mental health care, and psychotropic drugs) over time, adjusting for age and behavioral health diagnoses. We compared trends for gender minority beneficiaries (identified using diagnosis codes) to trends for a 5% random sample of other beneficiaries, stratified by original entitlement reason (age vs. disability). Results: Adjusted outpatient and inpatient mental health care use decreased and differences generally narrowed between gender minority and other beneficiaries over the study period. Among beneficiaries qualifying through disability, the gap in the number of outpatient and inpatient visits (among those with at least one visit in a given year) widened. Psychotropic drug use rose for all beneficiaries, but the proportion of gender minority beneficiaries in the aged cohort who had a psychotropic medication prescription rose faster than for other aged beneficiaries. Conclusions: Mental health care needs for Medicare beneficiaries may be met increasingly by using psychotropic medications rather than outpatient visits, and this pattern is more pronounced for identified gender minority (especially aged) beneficiaries. These trends may indicate a growing need for research and provider training in safe and effective psychotropic medication prescribing alongside gender-affirming treatments such as hormone therapy, especially for aged gender minority individuals who likely already experience polypharmacy.

MON-197 Peri-operative Outcomes of Vaginoplasty Using an Individualized Approach to Hormone Management in Transgender Women

For transgender and gender diverse individuals, gender identity is not congruent with the sex assigned at birth. Cross sex hormone therapy (HT) and gender affirming surgery can relieve significant dysphoria associated with gender incongruence and improve health outcomes. With changes in private insurance, state and federal regulations to cover gender-affirming treatments and procedures, there has been an increasing need and demand for trained providers and centers to provide gender-affirming health care. However, there is little data to guide management of peri-operative HT with regards to limiting risks. Most surgeons follow a protocol to stop feminizing HT 2 weeks before vaginoplasty with little data that this is effective and necessary or whether this might provoke significant dysphoria peri-operatively. We sought to determine if an age-specific and route-specific peri-operative protocol for feminizing HT was associated with increased risk for complications, changes in hormone concentrations or cardiometabolic profile. At our tertiary care academic center, transgender women over the age of 50 discontinued oral estradiol 6 weeks prior to surgery to allow enough time for clotting factors to normalize but could choose to switch to transdermal estradiol until 2 weeks prior to surgery. Younger women continued estradiol until surgery. All women restarted estradiol upon discharge from the hospital. We performed a retrospective review of pre and postoperative body mass index (BMI), blood pressure (BP), estradiol (E2) and total testosterone (TT) concentrations, fasting glucose and lipids 6 months before and after vaginoplasty. Results: A total of 59 transgender women underwent vaginoplasty over 20 months. Ten women age ≥ 50 (O) had a median age of 58 [Interquartile range (IQR) 56-62]. 49 women < age 50 (Y) had a median age of 31 [IQR 27-37]. O had significantly higher BMI than Y [29.7(IQR 28.3-34.2) vs 24.6 (21.6-28.4), p<0.01 and significantly higher BP, triglycerides, and LDL. More Y women were taking oral estradiol (53% vs 20%). There was no difference in baseline or post-surgical E2 or TT concentrations or fasting glucose. There were no complications of deep venous thrombosis, cardiovascular events or significant changes in BMI, BP, fasting glucose or lipids. In both age groups, only about half were able to decrease their estrogen dose post operatively (Y 57% vs O 44%, p=0.5). Conclusions: Continuing feminizing hormone therapy before vaginoplasty is not associated with an increased risk for complications in women under the age of 50. An individualized approach could be considered to limit the risk of worsening dysphoria post-operatively while avoiding increased risks in older women. Why estrogen doses could not be reduced more frequently after orchiectomy requires further investigation.

Common Hormone Therapies Used to Care for Transgender Patients Influence Laboratory Results.

Many laboratory tests are reported and interpreted with sex-specific reference intervals. However, transgender individuals receiving masculinizing or feminizing hormone therapy experience physiological changes predisposing some laboratory tests to shift outside of existing reference intervals. In this study, we review laboratory testing of a large cohort of transgender individuals who were prescribed hormone therapy for at least 6 months at an academic medical center. Transgender patients were identified using a search function within the electronic health record with gender identity status verified by chart review. Patients were grouped based on type of hormone therapy administered. All laboratory studies were ordered for medical purposes as part of clinical care; as a result, the exact laboratory tests differed among the patients. Some of the patients had sufficient data for both 6- and 12-month comparisons with baseline laboratory values. Statistically significant changes were observed at 6- and 12-month comparisons in basic chemistry, endocrine, and hematologic parameters for transgender individuals receiving masculinizing or feminizing hormones. Chart review demonstrated variation in route of administration of hormone therapy and frequency of gender-affirming surgery within the study population. Transgender individuals receiving hormone therapy experienced significant changes in components of basic chemistry, endocrine, and hematologic parameters following administration of hormone therapy. Variability in hormone dosing and route of administration for gender-affirming treatment warrants further investigation.

202. Expectations And Barriers To Fertility And Family For Transgender Youth

Gender affirming treatment for transgender and non-binary adolescents has been shown to decrease depression and suicidality, increase confidence, and reduce anxiety. In this way, gender affirming hormones can be viewed as life-saving medications, but treatments have medical and social risks. For example, hormone treatment for gender dysphoria may impact patients' future fertility and child bearing capabilities. In this study, we interviewed transgender and gender nonconforming (TGNC) adolescents and solicited their thoughts on parenting, biological children, and family. We completed 23 interviews with TGNC adolescents aged 13-19 who had previously been seen at the Seattle Children’s Gender Clinic. Research associates recruited TGNC adolescents between ages 13 and 21 to participate in a one on one semi-structured interview. We sought out a diverse sample of interviewees, with attempts to enroll transfeminine, transmasculine, and gender non-conforming/non-binary patients. Interviews lasted between 15 minutes and an hour and included a number of questions on fertility. Interviews were recorded, transcribed, and uploaded unto Dedoose version 8.0.42, a web application that allows for collaborative transcript review. Two research associates analyzed and coded the interviews according to the theory of thematic analysis. TGNC adolescents have myriad views on fertility, family, and the importance of having one’s own biological children. Of 23 participants 11 identified as transfeminine, 9 as transmasculine, and 3 as gender non-conforming. Eighteen of 23 participants expressed interest in having their own families one day, but only half expressed interest in those families including biological children. Participants identified a number of barriers to future fertility including the cost of fertility treatment as well as the fear that reproductive sparing procedures would slow or complicate one’s social or medical transition. Many interviewees described feeling as though they had to come to terms with infertility as part of the transition process. Participants rarely described discussing this topic with care providers. Participants also described feeling a sense of discord at having to make fertility decisions earlier than their peers, and a few discussed the hope that future medical advances could allow them to have biological children. The TGNC youth we interviewed expressed a wide range of views on fertility, influenced by both first-hand experience and personal preferences. Given the diverse expectations and goals of this patient population, further study is needed to create a care paradigm that can guide affirming, developmentally-appropriate fertility consultations for adolescents seeking gender care.

Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey.

To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients. Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August-November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes. Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health. This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.

Benefit of Gender-Affirming Medical Treatment for Transgender Elders: Later-Life Alignment of Mind and Body.

This study examined whether older age moderates the association between gender-affirming medical treatment and quality of life (QOL) among transgender individuals. Transgender men and women from the National Transgender Discrimination Survey who had either recently or never undergone medical treatment were included (n = 2420). A moderation analysis was utilized. As predicted, participants who initiated medical treatment had higher QOL than those who did not. Age moderated this association. The QOL difference was greater for older than for younger transgender individuals. Among all transgender men and women, gender-affirming medical treatment can be especially beneficial for elders.

Sociodemographic and Clinical Characteristics of Transgender Adults in Australia.

Background: Over the last 10 years, increases in demand for transgender health care has occurred worldwide. There are few data on clinical characteristics of Australian adult transgender individuals. Understanding gender identity patterns, sociodemographic characteristics, gender-affirming treatments, as well as medical and psychiatric morbidities, including neurobehavioral conditions affecting transgender and gender-diverse adults will help to inform optimal health service provision.Purpose: In an Australian adult transgender cohort, we aimed to first, assess referral numbers and describe the sociodemographic and clinical characteristics, and second, to specifically assess the prevalence of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD).Methods: We performed a retrospective audit of deidentified electronic medical records in a primary care and a secondary care gender clinic in Melbourne, Australia. Annual referral rates, sociodemographic data, and prevalence of medical and psychiatric conditions were obtained.Results: Data for 540 transgender individuals were available. Rapid rises were observed in referrals for transgender health services, more than 10 times the number in 2016 compared with 2011. Median age at initial presentation was 27 years (interquartile range (22, 36), range 16–74). Around 21.3% were unemployed and 23.8% had experienced homelessness despite high levels of education. Around 44.1% identified as trans male, 36.3% as trans female, and 18.3% as gender nonbinary. Medical morbidities were rare but mental illness was very common. The prevalence of depression was 55.7%, anxiety in 40.4%, ADHD in 4.3%, and ASD in 4.8%, all higher than reported age-matched general Australian population prevalence.Conclusions: Rising demand for transgender care, socioeconomic disadvantage, and high burden of mental health conditions warrants a comprehensive multidisciplinary approach to provide optimal care for transgender individuals. Given that ASD and ADHD are prevalent, in addition to gender-affirming treatments, psychosocial interventions may assist individuals in navigating health care needs and to support social aspects of gender transition. Further studies are required to understand links between ASD, ADHD, and gender identity and to evaluate optimal models of health service provision for transgender individuals.

Ethical Issues in Gender-Affirming Care for Youth.

Transgender and gender-nonconforming (TGNC) youth who suffer from gender dysphoria are at a substantially elevated risk of numerous adverse physical and psychosocial outcomes compared with their cisgender peers. Innovative treatment options used to support and affirm an individual's preferred gender identity can help resolve gender dysphoria and avoid many negative sequelae of nontreatment. Yet, despite advances in these relatively novel treatment options, which appear to be highly effective in addressing gender dysphoria and mitigating associated adverse outcomes, ethical challenges abound in ensuring that young patients receive appropriate, safe, affordable treatment and that access to this treatment is fair and equitable. Ethical considerations in gender-affirming care for TGNC youth span concerns about meeting the obligations to maximize treatment benefit to patients (beneficence), minimizing harm (nonmaleficence), supporting autonomy for pediatric patients during a time of rapid development, and addressing justice, including equitable access to care for TGNC youth. Moreover, although available data describing the use of gender-affirming treatment options are encouraging, and the risks of not treating TGNC youth with gender dysphoria are evident, little is known about the long-term effects of both hormonal and surgical interventions in this population. To support ethical decision-making about treatment options, we encourage the development of a comprehensive registry in the United States to track long-term patient outcomes. In the meantime, providers who work with TGNC youth and their families should endeavor to offer ethically sound, patient-centered, gender-affirming care based on the best currently available evidence.

Supporting sexuality and improving sexual function in transgender persons.

Sexuality is important for most cisgender as well as transgender persons and is an essential aspect of quality of life. For both the patient and their clinicians, managing gender dysphoria includes establishing a comfortable relationship with sexual health issues, which canevolve throughout the course of gender-affirming treatment. Gender-affirming endocrine treatment of transgender men and women has considerable effects on sex drive and sexual function. Gender-affirming surgery (GAS) can improve body satisfaction and ease gender dysphoria, but surgery itself can be associated with sexual sequelae associated with physical constraints of the new genitals or postsurgical pain, psychological difficulties with accepting thenew body, or social aspects of having changed gender. In general, a positive body image is associated with better sexual function and satisfaction, but satisfaction with sexual function after GAS can be present despite dissatisfaction with the surgery and vice versa. Factors involved inthe integrated experience of gender-affirming treatment and the way in which sexuality is perceived are complex, and supporting sexuality and improving sexual function in transgender patients is, correspondingly, multifaceted. As the transgender patient moves through their life before, during, and after gender-affirming treatment, sexuality and sexual function should be considered and maximized at all stages in order to improve quality of life.

Endocrinology of Transgender Medicine.

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.

Semen Parameters Among Transgender Women With a History of Hormonal Treatment

ObjectiveTo report on the semen quality parameters in transgender women who pursued semen cryopreservation either in the presence or absence of gender-affirming hormonal medication. Materials and MethodsThis retrospective cohort study was conducted as a chart review of consecutive transgender women presenting for semen cryopreservation between January 1, 2012 and March 31, 2018. Demographic data and semen parameters were assessed. Primary outcomes were the semen parameters in subjects with either no exposure, previous exposure or current exposure to gender-affirming hormonal medication. ResultsTwenty-eight patients presented for semen cryopreservation and produced 69 specimens. Using a Kruskal-Wallis test, semen analyses were compared between patients who had never used gender-affirming hormonal medication, those who had previously used hormonal medication but discontinued prior to specimen collection, and those who used medication at the time of specimen collection. Median semen parameters for each group were as follows: volume—2.7 mL, 2.1 mL, 0.9 mL, respectively (P = .12); concentration—63.6 M/mL, 39.0 M/mL, 2.4 M/mL, respectively (P < .01); percent motility—51.5%, 34.3%, 15.6%, respectively (P < .01); and the total motile count was 63.2 M,39.1 M, 0.2 M, respectively (P < .01). Fifteen specimens were collected after discontinuing hormonal medication with a mean discontinuation period of 4.4 months. ConclusionSpecimens collected in the presence of hormonal medication were associated with abnormal semen parameters. Specimens collected after discontinuation of gender-affirming treatments were comparable to transgender women who had never used hormonal medication. Transgender women should be counseled about the potential impact of gender-affirming hormones and to consider fertility preservation prior to gender-affirming treatments.

Proportion of adults in the general population of Stockholm County who want gender-affirming medical treatment.

The number of patients presenting for care at gender clinics is increasing, yet the proportion of adults in the general population who want gender-affirming medical treatment remains essentially unknown. We measured the wish for cross-sex hormones or gender-affirming surgery, as well as other aspects of gender incongruence, among the general adult population of Stockholm County, Sweden. A population-representative sample of 50,157 Stockholm County residents ages 22 and older comprise the Stockholm Public Health Cohort. They were enrolled in 2002, 2006, and 2010 and followed-up in roughly 4-year intervals, with questions on health, lifestyle and social characteristics. In 2014, participants received the item “I would like hormones or surgery to be more like someone of a different sex.” Two additional items concerned other aspects of gender incongruence: “I feel like someone of a different sex”, and “I would like to live as or be treated as someone of a different sex.” Each item had four answer options (“Not at all correct”, “Somewhat or occasionally correct”, “Quite correct”, and “Absolutely correct”). For each item, any of the three affirmative answer choices were considered as some level of agreement. Calibration weights were used to estimate population-representative rates with 95% confidence intervals. The desire for cross-sex hormones or surgery was reported by 0.5% (95% CI, 0.4%–0.7%) of participants. Feeling like someone of a different sex was reported by 2.3% (95% CI, 2.1%–2.6%). Wanting to live as or be treated as a person of another sex was reported by 2.8% (95% CI, 2.4%–3.1%). These findings greatly exceed estimates of the number of patients receiving gender-affirming medical care. Clinicians must be prepared to recognize and care for patients experiencing discomfort due to gender incongruence and those who would like gender-affirming medical treatment.

International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q)

IntroductionA critical barrier to outcome assessment in gender-affirming healthcare is the lack of a specific patient-reported outcome measure (PROM). This phase I protocol describes an international collaboration between investigators in...

Exploring Cross-Sectional Predictors of Suicide Ideation, Attempt, and Risk in a Large Online Sample of Transgender and Gender Nonconforming Youth and Young Adults.

Rates of suicide ideation and attempt appear to be particularly high in the transgender and gender nonconforming (TGNC) population, yet little is known about which factors are the most salient contributors for TGNC young people and how these contributors vary across suicide-related outcomes. Within the largest sample of TGNC young people to date (N = 1896; ages 14-30), we examined the contribution of demographics (age, assigned sex, gender identity, sexual orientation identity, race/ethnicity, and socioeconomic status), minority stress (gender-related affirmation, gender-related self-concept, victimization, and gender-affirming medical treatment desire/access), social support (from family and friends), and depressive symptoms in the cross-sectional prediction of three suicide-related outcomes: past-year attempt, past-year ideation, and a composite measure of suicide risk. Each set of factors explained significant variance in each outcome; however, only several predictors remained significant in each of the full models. Gender-related victimization and depressive symptoms were independent predictors for all three outcomes. Additional predictors varied across outcome. Age, male identity, sexual orientation-based victimization, and friend support were associated with suicide attempt. Age, queer identity, gender-related self-concept negativity, and family support were associated with suicide ideation, and pansexual identity and gender-related self-concept negativity were associated with positive suicide risk screen. Prevention and intervention efforts aimed at building support and positive self-concept, decreasing victimization, and treating depression are likely to partially reduce suicide ideation and attempt in TGNC adolescents and young adults. Comprehensive interventions with younger adolescents are particularly critical.

Assessment and Treatment of Gender Dysphoria and Gender Variant Patients: A Primer for Psychiatrists.

Assessment and Treatment of Gender Dysphoria and Gender Variant Patients: A Primer for Psychiatrists.

Transgender adolescents and legal reform: How improved access to healthcare was achieved through medical, legal and community collaboration.

Transgender children and adolescents face hardships in all domains of their lives, with many experiencing family rejection, social exclusion, discrimination, bullying and assaults. The mental health implications of these experiences include high rates of depression, anxiety, self-harm and attempted suicide. Gender-affirming social support and medical treatment has been shown to ameliorate the poor mental health outcomes of transgender youth, with those who are supported in their social and medical transition reporting rates of depression and self-worth equivalent to general population levels. Advocacy efforts that improve access to support and medical treatment are therefore likely to produce significant positive health and well-being outcomes for this vulnerable population. The transgender community in Australia identified the legal restrictions placed on children and adolescents accessing medical treatment as a significant barrier to positive psychological well-being. Australian law, unique internationally, required the parents of transgender adolescents to apply for court authorisation prior to the commencement of their child's gender-affirming medical treatment. Concerned by the harm created by this process, a coalition of experts, including transgender children, adolescents and their parents, as well as academic and clinical experts in the fields of law and medicine, was created to advocate for reform. Over a period of approximately 4 years, a collaborative process was undertaken, which ultimately led to law reform and improved access to medical treatment for the transgender community.

Psychiatrists Need to Prepare to Care for Gender-Variant Patients

Back to table of contents Previous article Next article From the ExpertsFull AccessPsychiatrists Need to Prepare to Care for Gender-Variant PatientsEric Yarbrough,M.D.Eric Yarbrough,Search for more papers by this authorM.D.Published Online:7 Sep 2018https://doi.org/10.1176/appi.pn.2018.9a17AbstractEric Yarbrough, M.D., is director of psychiatry at Callen-Lorde Community Health Center in New York City and president of AGLP: The Association of LGBTQ Psychiatrists. At APA, he is vice chair of the Council on Minority Mental Health and Health Disparities and a member of APA’S LGBTQ Caucus. He is the author of Transgender Mental Health from APA Publishing. APA members may purchase the book at a discount.The concept of gender, or what people generally think of as the state of being male or female, is something that is so deeply engrained in our culture that attempts to even bend it are met with hostility from individuals and groups, both political and religious. Given our society’s appreciation of individual freedom, it has never made sense to me that the presentation of someone’s gender outside the expected upsets so many.The number of trans-identified individuals seeking care for gender-affirming services has increased dramatically over the past few years. This could be due in part to the depathologizing language change from gender identity disorder to gender dysphoria in DSM-5. This change communicated a shift in psychiatric thinking regarding gender diversity, which provided a metaphorical welcome sign to those who previously felt uncomfortable or unsafe seeking psychiatric care. The increase in gender-diverse people seeking services could also be due to insurance coverage of gender-affirming treatments such as hormone therapy and surgical procedures. As more transgender and gender-nonconforming patients are coming out and making new patient demands, the psychiatric community must be prepared to care for more gender-diverse individuals. The first step in the process includes examining how we think about gender. I work at an LGBTQ clinic in New York City, and dealing with the many identities on the gender spectrum is a regular part of my work day. The idea that “male” and “female” are not a dichotomy but can exist simultaneously or not at all is part of an assumed position when working at a place like Callen-Lorde. When I speak at schools, clinics, and hospitals, it is generally about LGBTQ mental health and more recently about transgender mental health. Part of my introduction to the topic is discussing the gender spectrum, and I ask clinicians to think about what parts of their presentation are typically masculine and feminine. Surprisingly, mental health professionals—those who are thought to be the most in tune with their ideas and emotion—are sometimes defensive about the notion that their gender might be more complicated than the single identifier onto which they have held so closely since childhood.It is good practice for all psychiatrists to be aware of their own gender and to examine the spectrum that exists within their own identity. When psychiatrists are open to exploring their own gender and gender expression, it is easier for them to approach gender-diverse patients as individuals and provide the best care. Letting go of the conventional definitions of masculinity and femininity is the first step to moving past the old gender dichotomy. Being self-aware will keep in check our own gender stereotypes and help us pay attention to the automatic assumptions that influence our daily thinking.What is considered to be masculine and feminine behavior, attitudes, and fashion are cultural stereotypes that have been engrained in us from an early age. While some stereotypes might have biological roots, the majority are probably societal inventions. With the emergence of hormone and surgical treatment options for gender dysphoria, we are in a unique place to examine and deconstruct some of the core concepts of what makes up gender. Through supervising other clinicians who work with individuals with gender dysphoria and exploring my own experience, I know that there are so many automatic reactions, thoughts, and ideas that require significant additional introspection. It is best that we start having conversations about them to free us up to provide sensitive and quality care. And as we do so, we will likely learn just as much about our changing society and our culture as about ourselves. ■ ISSUES NewArchived

Access to Care Remains Problematic for Transgender Patients

Access to Care Remains Problematic for Transgender Patients