Transgender individuals with mental illness benefit from modernized psychiatric care

Psychiatrists play an important role in the care of transgender individuals with mental illness and substance use disorders, according to a presenter at the Psych Congress 2020 Virtual Experience conference.

“Transgender care does reduce gender dysphoria, improves quality of life on quality of life measures and has a low regret rate,” Dan Karasic, MD, clinical professor of psychiatry at University of California, San Francisco, said during the presentation.

According to Karasic, some of the emphasis on mental health and mental health evaluations for transgender individuals emerges from a “historical” context and may need to be evaluated in light of current standards of care. However, some modern measures, such as the California Health Interview Survey conducted between 2015 and 2016, have suggested elevated rates of mental health symptoms, including suicidal thoughts and serious psychological distress, among transgender individuals.

Karasic provided an overview of the importance of updated standards set to be released in the coming World Professional Association for Transgender Health (WPATH) Standards of Care Version 8. One chapter will focus on the management of mental health conditions, and it will feature contributions from an array of psychiatrists across the world, Karasic noted. A major task the authors faced in updating the WPATH Standards of Care centered around the “well-controlled” descriptor of mental illness.

“[The notion] that mental illness must be well-controlled in order to get transgender surgeries, or reasonably well-controlled for hormones, is vague and not that helpful for people and increasingly not standard practice,” Karasic said. “A big task was to come to consensus about how having a mental illness or a substance use disorder might impact someone's access to transition care and how it should be addressed by mental health professionals when somebody is seeking transition care, so we are replacing the well-controlled descriptor.”

Instead, Karasic and the other contributors to WPATH Standards of Care 8 advise mental health professionals to address mental health symptoms that interfere with a person’s capacity to give informed consent. For example, Karasic noted that a patient with a psychotic disorder might be unable to fully understand the risks and benefits of transition surgery, which may remain a barrier to care until the illness is sufficiently treated. Beyond consent, it is also important for clinicians to determine the impact of mental illness on the ability of a transgender individual’s ability to move forward in the care process.

“For example, someone's substance use disorder might need to be brought into sufficient control so that the person can make it to their appointments with their physician or with their surgeon and go to follow-up care postoperatively,” Karasic said. “If it's felt that the mental illness or substance use disorder is sufficiently impairing that somebody can't do that, then this should be addressed before surgery. It really is weighing risks and benefits, such as if an intervention can be made in the short term, with minimal risk in terms of the impact of delaying surgery, and whether that might make a big difference in terms of outcome.”