Dan H. Karasic

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

ABSTRACT The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Transgender people: health at the margins of society

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed HIV-positive adults: a randomized controlled trial.

OBJECTIVES We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008. METHODS We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL). RESULTS The intervention reduced depression symptom severity (b = -1.97; 95% confidence interval [CI] = -0.85, -3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes. CONCLUSIONS Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.

Recommendations for revision of the DSM diagnosis of gender identity disorder in adults

The World Professional Association for Transgender Health (WPATH) conducted a consensus process in order to make recommendations for revision of the DSM diagnoses of Gender Identity Disorders. This is a report from the work group proposing new diagnostic criteria for Gender Identity Disorders for adults if the diagnosis were to be retained in the next revision of the DSM. The group recommended changing the diagnosis to one based on distress rather than on identity, on which the current diagnosis is based. Hence, they proposed changing the name of the diagnosis from Gender Identity Disorder to the more accurate and less pathologizing Gender Dysphoria, a name familiar to the field, used before, and describing the condition of distress. They proposed the following criteria for a diagnosis of Gender Dysphoria in Adults: (a) strong and persistent distress with physical sex characteristics or ascribed social gender role that is incongruent with persistent gender identity, and (b) the distress is clinically significant or causes impairment in social, occupational, or other important areas of functioning and this distress or impairment is not solely due to external prejudice or discrimination. There was consensus that a transgender identity is not pathology. Gender variant individuals are not inherently disordered; rather, the distress of gender dysphoria is the psychological problem.

Homophobia: Therapeutic and Training Considerations for Psychiatry

A ubiquitous aspect of contemporary society, homophobia has important intrapsychic consequences. This overview examines therapeutic considerations for psychiatrists and other clinicians working with patients whose identifiable sexual orientation (whether bisexual, lesbian, “queer,” or gay) is enough homoerotic to be the target of homophobia in latency, adolescence, and young or older adulthood. It explores the relationship between perceived or introjected homophobia, self-destructive behavior, and psychological symptoms. Treatment of patients for whom the homoerotic is part of sexual identity can be improved by educating psychiatrists throughout their training and practice about sexual identity formation, the “coming out” process, the internalization of homophobia, and the integration of sexuality with identity in homoerotically identified patients. Recommendations are made for the individualized, empathic treatment of identified homoerotic patients. The impact of homophobia on the psychiatrist and the psychiatrist in training is also discussed.

Does substance use compromise depression treatment in persons with HIV? Findings from a randomized controlled trial†

ABSTRACT Depression and substance use are significant obstacles to effective HIV care. Using data derived from a randomized controlled trial of persons with HIV who are homeless or marginally housed, this study assesses the utility of antidepressant treatment among persons with HIV, depression, and active substance use. Participants were diagnosed with depressive disorders and randomly assigned to receive directly observed therapy with fluoxetine or a referral to community mental health treatment. Assessments, conducted at baseline and every 3 months over a 9-month period, included the Hamilton Rating Scale for Depression, the Beck Depression Inventory II, and self-report of alcohol, crack, cocaine, heroin, or methamphetamine use in the past 90 days. To investigate the effect of antidepressant treatment in the setting of active substance use, the authors fit mixed-effects linear regression models to estimate the effect of directly observed fluoxetine on depressive symptom severity after stratifying by any alcohol use or any illicit drug use. To investigate whether alcohol use or illicit drug use moderated the antidepressant treatment response, the authors examined the interaction terms. The effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant irrespective of alcohol use status. When stratified by illicit drug use status, the effect of directly observed fluoxetine treatment on depression symptom severity was statistically significant only among persons who did not use illicit drugs. The interaction terms were not statistically significant. This study found a benefit of antidepressant treatment in persons with HIV, depression, and alcohol use. In addition, this study found no evidence that either alcohol use or illicit drug use moderates the antidepressant treatment response. Altogether, these findings support the use of antidepressant medication in this population. The public health impact of research in this area is significant given the known adverse effects of depression on HIV-related health outcomes. ClinicalTrials.gov Identifier: NCT00338767.

Multidisciplinary Care and the Standards of Care for Transgender and Gender Nonconforming Individuals

In providing care to transgender patients, surgeons interact with health care providers of other disciplines, including medical and mental health providers. Mental health or medical providers often see a patient first, when hormones are initiated. The Standards of Care recommend that mental health professionals assess patients for surgery according to set criteria and send surgeons their evaluations prior to surgery. Open communication is essential between surgical, medical, and mental health providers as well as with patients, who must give informed consent. A patients multidisciplinary team can continue to provide care across a patients life span.

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

The Board of Trustees of the American Psychiatric Association (APA) has approved as a Resource Document a report of the APA Workgroup on Treatment of Gender Dysphoria titled “Assessment and Treatment of Gender Dysphoria and Gender Variant Patients: A Primer for Psychiatrists.” The APA Workgroup was assembled to work toward fulfillment of the recommendations of the APA Task Force on Treatment of Gender Identity Disorder. Although diagnosis and treatment are inextricably linked, they are separate issues. Both the diagnosis and treatment of gender identity disorder were controversial, and the respective DSM-5workgroup set up in May 2008 drew much professional and public attention. Because diagnosis, but not treatment, is within the purview of the DSM, the APA Board of Trustees formed the Task Force on Gender Identity Disorder to 1) conduct a literature review to assess the quality of evidence pertaining to the treatment of gender identity disorder in different age groups and 2) express an opinion as to whether sufficient credible literature existed for APA to take the next step and develop treatment recommendations for gender identity disorder in children, adolescents, or adults as well as for individuals of any age with somatic intersex conditions who experience dysphoria related to their assigned gender. The Task Force reported that, given the nature of gender identity disorder, evidence of the highest quality—the randomized double-blind controlled trial—was not available. The Task Force concluded, nevertheless, that the empirical database supplemented by clinical consensus was sufficient for the development of treatment recommendations. In addition to recommending the development of treatment recommendations, the Gender Identity Disorder Task Force recommended that APA take a number of additional actions, including tasking a specific APA component or other group within the APA to monitor progress with regard to implementing its recommendations, which led to the formation of the APA Workgroup on Treatment of Gender Dysphoria. Despite the recommendation of the Task Force, treatment of gender dysphoria could not be selected for APA Clinical Guideline development because it did not meet prevalence and quality of evidence criteria to be prioritized for consideration by the APA Committee on Practice Guidelines. Several clinical guidelines and standards of care exist to assist mental health professionals in providing care to individuals with gender dysphoria but are not targeted specifically toward psychiatrists. These include the World Professional Association for Transgender Health Standards of Care, version 7, published in 2012, and the American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People published in 2015. Although the practice of psychiatry overlaps with that of other mental health fields, psychiatry is unique in several respects. Psychiatrists often have the primary role in the diagnosis and treatment of themajormental illnesses in which gender identity concerns may arise as epiphenomena (e.g., psychotic disorders) as well as in the pharmacological management of psychiatric disorders that may coexist with gender dysphoria, including mood and anxiety disorders, and in monitoring symptoms that may emerge with endocrine manipulation. While targeted specifically to psychiatrists, the APA Workgroup’s Resource Document should be helpful to providers in other disciplines, since all are likely to encounter gender diverse patients. The Resource Document begins with a review of the history and evolution of conceptualizations of gender and gender variance and its classification and related terminology, including differences between DSM-IV and DSM-5. It then examines the prevalence of gender dysphoria and other manifestations of gender variance before reviewing what is known about gender development. The largest portion of the document addresses the mental health assessment and treatment of gender dysphoria in adults, including those with somatic intersex conditions. This includes mental health evaluations and referrals forgender-affirmingsomatic treatments.Thedocument concludes with an examination of current societal trends, including increased social acceptance of gender variance, civil protections for gender diverse individuals, and increased access to gender transition services for adults (specific guidance on thesematters for child and adolescent psychiatrists can be found in the American Academy of Child and Adolescent Psychiatry Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents). The report includes a glossary of gender terminology and tables of the currently most widely accepted criteria for gender-affirminghormonal and surgical treatments. The full Resource Document accompanies the online version of this APA Official Action (ajp.psychiatryonline.org). A version of the report revised through peer review is also available https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944396.