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Mental Health Care and Assessment ofTransgender AdultsDan Karasic, MDHealth Sciences Clinical Professor of Psychiatry, University of California San FranciscoUCSF Alliance Health Project UCSF Transgender Surgery ProgramCastro Mission Health Center Transgender Life Care and Dimensions [email protected]

Continuing Medical Education Disclosure Program Faculty: Dan Karasic, MD Current Position: Clinical Professor of Psychiatry, University of California, San Francisco Disclosure: No relevant financial relationships. Presentation does not include discussion of off-labelproducts.It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff discloserelationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interestand, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to anidentified resolution process prior to their participation were involved in this CME activity.

Challenges with Expanding Access toSurgery Co-occurring mental health and substance use disorders History of trauma, societal discrimination, negative experiences inmedical and mental health care settings may interfere with engagementin care Unstable living situations and lack of social support Lack of resources in health care and mental health care settings

What Psychiatrists and Other Mental HealthPractitioners Can Contribute Providing care to stabilize co-occurring mental health and substanceabuse disorders with transition and across the lifespan. Principles of cultural humility and patient centered care. Emphasis on psychosocial functioning and support.

What Psychiatrists and Other Mental HealthPractitioners Can Contribute Principles of psychiatric consultation in evaluating for surgery Training mental health teams Advocacy in health systems

Roles in Gender Teams UCSF Alliance Health Project: Formed new Gender Team, trained staff, set protocols,monthly supervision meetings, second letters Castro Mission Health Center: Longstanding gender teams: Dimensions andTransgender Life Care Program. Hired additional staff. Added monthly supervisionmeeting. Structured interview form for mental health assessments. Women’s HIV Clinic at SFGH: Strong existing multidisciplinary team. Patients with highrates of co-occurring psychiatric illness and substance abuse, and psychosocialchallenges. Training staff, setting protocols. UCSF Medical Center Transgender Surgery Program: Building institutional support,setting protocols, reviewing letters, evaluations for second letters, research agenda

There are More Trans People Than OnceThought Massachusetts phone survey: 0.5% identified as transgender(N 28,000 ). (Conron, et al 2012) Netherlands: 0.8%-1.1% (N 8000 ) identified as gender incongruent(Kuyper and Wijsen, 2014) New Zealand: 1.2% of 8,000 high school students identify astransgender. (Clark TC et al 2014) Numbers seeking binary transition at gender centers is much smaller, butgrowing rapidly. (Dhejne et al 2013)

Psychiatric Assessments for HormoneTherapy and WPATH SOC 7 Elimination of 12 weeks of psychotherapy or 12 weeks living in role of“opposite sex” Presence of persistent gender dysphoria and ability to give informedconsent is basis for hormonal treatment Hormonal therapy indicated for gender dysphoria across the genderspectrum Mental illness should be “reasonably well-controlled” per SOC 7 Concurrent treatment of Gender Dysphoria with co-occurring mental illness oftenis necessarySOC 7 free download at wpath.org

SOC 7: Access to Care WPATH SOC 7 brings “informed consent” clinics under SOC. These clinics do not require a letter from a mental health professional tostart hormones, which lowers barriers to care. However “informed consent” clinics are expected by SOC to refer thosewith mental health issues for treatment.

Closing the Gap: WPATH SOC 7 and the“Informed Consent” Model Community clinics, often using a team approach, are providing hormonaltherapy without a letter from a mental health professional Assessment is more than just having the capacity to understandrisks/benefits: experienced medical providers use clinical judgment thathormonal therapy is indicated Clinics often have mental health providers for referral when indicated byintake staff or medical provider

Care for Trans Patients with Co-occurringMental Illness Simultaneously addressing mental illness, substance abuse, and genderdysphoria is often necessary, while working to optimize functioning intrans people with co-occurring psychiatric illness

Hormone Therapy and Co-occurring MentalIllness Hormone therapy is safe and effective for gender dysphoria in patients with severemental illness, though mood symptoms can occur. Hypomania/mania with testosterone is uncommon, even with supraphysiologic doses,though bipolar patients should be followed closely at time of initiation. Occurred in 2/50 cis men given 600mg/week testosterone. (Pope, et al, Arch Gen Psychiatry 2000) Reduced mental health symptoms overall in trans men with testosterone treatment;weekly injections better tolerated than every 2 weeks. (Davis& Meier, 2013) Risk/benefits must be weighed, including mental health improvement with relief ofgender dysphoria, and harm from withholding care.

SOC 7 Criteria for Surgery Persistent, well-documented gender dysphoria Capacity for informed consent, and of age to consent If significant medical or mental health concerns are present, they must bewell-controlled.

SOC 7 and Social Transition Social transition is not a requirement for hormones, chest/breast surgery,hysterectomy/salpingo-oophorectomy, or orchiectomy For vaginoplasty, metoidioplasty, phalloplasty: 12 continuous months ofliving in a gender role congruent with gender identity

SOC 7 and Surgery: Hormones Chest surgery for trans men: Hormone therapy not a prerequisite Breast augmentation in trans women: Hormone therapy recommendedfor at least 12 months (for better outcome) Genital surgery: 12 continuous months of hormone therapy (unless notclinically indicated)

SOC 7 and Surgery: wpath.org SOC 7 requires one mental health assessment for chest surgery and twofor genital surgery From 2 licensed, knowledgeable mental health professionals.

Mental Health Assessments and Letters forSurgery Letter is the consultation report to the surgeon and necessarydocumentation for insurance coverage Letter should provide necessary information for surgeon’s ownassessment and care of patient Assessor should be a resource for the surgeon after the consultation iswritten Assessment process can aid in patient education and preparation forsurgery

What’s in a Letter? Dated and addressed to surgeon Name and date of birth of patient Who the assessor is, and the assessor’s relationship with the patient. E.g.: “I am a licensed clinical social worker, and saw AB weekly from JulyDecember, 2014, for psychotherapy and for an assessment for genital surgery.”

What’s in a Letter? (2) The history of the patient’s gender dysphoria, and what treatment (e.g.psychotherapy, hormones, other surgeries) the patient has alreadyundergone. The patient’s social transition, with pertinent details. (e.g., when thepatient started living in full time their current gender role, relationshipsand functioning in current gender role, legal name/gender change.) For genital surgery, specify length of time on hormones and in currentgender role, meeting SOC 7 one year requirement.

What’s in a Letter? (3) History of mental illness and substance abuse Current medical or mental health conditions, current medications, andlevel of stability of these conditions. Capacity for informed consent, and patient’s understanding of the risksand benefits of the planned surgery. Fertility discussion, when appropriate. Psychosocial stability: Housing, support, plan for post-operative period.

What’s in a Letter? (4) Diagnosis: Gender Dysphoria, Co-occurring conditions A statement that the patient meets SOC 7 criteria for the surgery. A request that the surgeon contact you (at 415-XXX-XXXX) if furtherinformation is needed.

The Second Assessment and Letter Typically scheduled after first assessment is complete. Letter from first assessment reviewed, and case discussed with firstassessor, when necessary, before second assessment. First assessment letter reviewed with patient Independent assessment of patient, including diagnosis, co-occurringconditions, ability for informed consent and understanding ofrisks/benefits of planned surgery, and current psychosocial stability andaftercare plan. Availability to speak with the surgeon, if necessary

Case Vignette #1: Assessment forVaginoplasty in Patient with Diagnosis ofBorderline Personality DisorderPsychiatry resident requests supervision on case: 61 yo trans F, seeing UCSF residents serially for several years, has been seeing this resident in psychotherapy for almost 2 years.H/o multiple suicide attempts, but none in last several yearsOn hormone therapy and living as female for decadesS/P orchiectomy many years ago for testicular cancer.Learns that vaginoplasty is now available; seeking “letter” immediately toget in queue.

Considerations in this patient1. The patient meets SOC 7 criteria of persistent gender dysphoria, one2.3.4.5.year social transition and on hormones, and (likely) capacity forinformed consent.Is the patient stable for surgery: medically, mentally, and psychosocially?Does she have realistic expectations for surgery?Can concerns about stability and realistic expectations be addressed intherapy? Is there any reason to delay for a better outcome?How does one maintain a therapeutic alliance while acting as agatekeeper?

National Transgender Discrimination Survey:Survey of 7000 Trans People Refusal of health care: 19% of our sample reported being refused caredue to their transgender or gender non-conforming status Harassment and violence in medical settings: 28% of respondents weresubjected to harassment in medical settings and 2% were victims ofviolence in doctor’s offices Lack of provider knowledge: 50% of the sample reported having to teachtheir medical providers about transgender careGrant JM et al, 2010

Table 2. Risk of various outcomes among sex-reassignedsubjects in Sweden (N 324) compared to population controlsmatched for birth year and birth sex.Dhejne C, Lichtenstein P, Boman M, Johansson ALV, et al. (2011) Long-TermFollow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery:Cohort Study in Sweden. PLoS ONE 6(2): 0016885

Figure 1. Death from any cause as a function of time after sex reassignment among 324transsexual persons in Sweden (male-to-female: N 191, female-to-male: N 133), andpopulation controls matched on birth yearDhejne C, Lichtenstein P, Boman M, Johansson ALV, et al. (2011) Long-TermFollow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery:Cohort Study in Sweden. PLoS ONE 6(2): 0016885

Regret Rate by Decade, Sweden 1960–1971 4/15 (27 %) 0 1972–1980 6/103 (5.8 %) 5 1981–1990 1/76 (1.3 %) 3 1991–2000 3/127 (2.4 %) 3 2001–2010 1/360 (0.3 %) 4 1960–2010 15/681 (2.2 %) 15Dhejne, et al, Arch Sex Behav 2014

Case Vignette #2: Trans Man withDepression, Seeking Chest Surgery 20 yo assigned female at birth, now identifies as trans male. Referred by chest surgeon for mental health assessment for surgery. Reports being a “tomboy,” but only recognizing trans identity in past two years. Out to family; has used male name and pronoun only with online communities.Socially isolated and uncomfortable leaving home. Started testosterone 7 months ago, with lowered voice and some body hair. Sees psychologist weekly (depression CBT) and psychiatrist monthly (antidepressants)with little improvement, since being brought in for psychiatric evaluation after onlinefriend called 911, concerned about suicidality. Neither psychologist nor psychiatristfelt comfortable doing the one necessary evaluation for chest surgery. Pt feels persistent discomfort with breasts, and with being perceived as female.

Trans Man Seeking Chest Surgery: WPATHSOC 7 Pt has persistent gender dysphoria. Pt has capacity to understand risks and benefits of surgery. SOC 7 allows for chest surgery early in transition, including beforetestosterone or social transition. Has family support post-operatively.Is mental illness “stable”? Should the criteria be instead that the mentalillness does not affect capacity or judgment, and that the mental healthbenefits of surgery outweigh the risks?

Case vignette #3: Genderqueer YouthSeeking Unconventional Surgery A. is an African American genderqueer youth seen at Dimensions Clinic, in early 20’s, followed for last 4 years at Dimensions Clinic.Gender identity neither male nor female, but they had strong gender dysphoria aboutpenis, masculine features.Presented with untreated bipolar disorder, Type II, and alcohol use disorderGender dysphoria treated concomitantly with addressing mood disorder and alcohol use.Treated first with spironolactone, then estradiol added; presentation gradually becamemore feminine.Peer support and culturally sensitive clinical environment helped maintain therapeuticallianceNow presents seeking “genital nullification.”

Genderqueer Youth: Considerations forSurgeryConsiderations: A. has capacity for informed consent and longstanding documented gender dysphoria Has only moderate preference for “nullification” over conventional vaginoplasty A.’s