Transgender Care: A Psychiatric Perspective

MedPiper Technologies and JournoMed had conducted a Webinar Series to “Improve Healthcare Access for Transgender and Sexual Minorities For The Doctors and By The Doctors” with IRIA Kerala- Raksha, Shakthi, Social Wings, IMA Kerala and CARB. On Day 4, 20th July, 2022, Dr. U Vivek discussed about Transgender Care- A Psychiatric Perspective. Dr U Vivek is a Consultant Psychiatrist from Renai Medicity Hospital, Kochi, Kerala.

Transgender and gender-diverse individuals face substantial barriers in accessing healthcare. It includes healthcare professionals’ biases to some extent and lack of knowledge regarding practices such as hormone therapy or gender affirmation surgery. Many transgender and gender-diverse individuals report being refused medicare due to harassment. However, bias and discrimination are slowly reducing as people are being educated and as time progresses. Providing inclusive gender-affirming care helps in reducing barriers and allows the individuals to obtain substantial care.

Gender diversity is different for different people. Gender diversity is perhaps a challenging task and it is the navigating how one expresses themselves to society. It entirely depends upon individual personal choice. 

LGBTQIA+ is the abbreviation for lesbian, gays, bisexual, transgender, queers, intersex, asexual or more. The terminology describes a person’s sexual orientation or gender identity. All these individuals feel insecure to face society to a significant extent. However, the attitude toward the LGBTQIA+ community has changed recently and is being accepted. There are still cases of homophobia and discrimination to a major extent. Due to the discrimination and bias, these individuals are forced to migrate to other cities which are transgender friendly. Kerala is a more transgender-friendly state in recent times. 

Some people experience gender diversity as a wonderful experience filled with possibilities while some struggle to express complexity of their internal gender identity. People have their unique ways of exploring, experiencing and expressing their gender identity.

Gender identity is the internal, psychological or spiritual sense of self relative to one’s degree of maleness or femaleness. This can be in opposition to the socially defined idea of one’s gender. Few definitions regarding gender and sensitivity are discussed below.

1. Sex is the physical classification of a person as male or female by their reproductive organs, functional anatomies, chromosomes and their hormones. 
2. Intersex is a general term used for varied conditions in which a person is born with reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. 
3. Gender refers to the culturally and socially determined meanings assigned to males and females and a label is placed on individuals. Each society emphasizes particular gender roles that each sex should play. Although there is usually a wide latitude in acceptable behaviours for each gender. 
4. Gender identity refers to the internal, psychological or spiritual sense of self relative to one’s degree of maleness or femaleness. This can be in opposition to the socially defined idea of one’s gender. 
5. Transgender is a person whose internal gender identity doesn’t match the anatomical sex with which they are born. Consequently, the socially defined gender label assigned to match the physical sex creates a conflict within the person. 
6. Transexual is a medical term that refers to a person whose gender identity differs from what is culturally associated with their biological sex at birth and who wishes to undergo sex reassignment surgery.
7. Gender Expression is a way a person reveals their gender to others. It could be clothing, jewelry, hairstyle, an occupation, status in society, communication style etc. 
8. Sexual Orientation is a pattern of emotional, romantic and sexual attraction (not a behaviour). 

Note: Orientation is not a choice. Researchers suggest that it’s a combination of genetic, hormonal, environmental and biological factors before birth. 

The issues that gender diverse or transgender individuals face include:

• Family acceptance and social issues: Many individuals experience gender dysphoria and even fear of revealing their gender identity. While few families accept the gender of the individual, few people approach psychiatrists for sex reassignment or gender reassignment surgeries. 
• Many individuals suffer from drug, alcohol and gender dysphoria conditions and dive into depression and anxiety. 
• Mental health challenges : Many gender-diverse and transgender individuals face anxiety, depression, stress, drug abuse, addiction etc. They even experience trouble from relationship issues with their parents, friends and colleagues and they land into unhealthy relationships. Partners walk out. They end up with suicidal thoughts etc. So mental health challenges are huge among such people and need to be addressed. Individuals who are identified as transgender individuals tend to experience higher rates of mental health issues than the general population. 

Studies reveal the risk of developing a mental health condition was from 3-13 times higher for transgender and gender non-conforming youth than those whose gender identity corresponded with their assigned gender at birth. 

There are many psychological issues faced by gender-diverse and transgender individuals. Most common among them is depression along with low mood, anxiety, tension, lack of motivation, self-harm thoughts, suicidal thoughts etc. Social anxiety disorder occurs when they interact with people. Bipolar disorders arise as an alternating depressive and manic episodes. Impulse resource disorder and Borderline personality disorder are quite common disorders which lead to mood swings, impulsivity, low-stress tolerance, sensitivity, self-harm etc. Suicidal thoughts and para-suicidal thoughts, abuse- sexual abuse and child abuse are quite common among these populations. Most psychological problems are common among these populations. There are a lot of unrevealed problems that remain difficult to diagnose as they progress towards advanced stages.

Physician’s Consultation at Transgender Clinics

• As a doctor or any other professional, one needs to be non-judgmental and unbiased. Always listen to transgenders patiently. 
• A multi-disciplinary team is involved in working to take care of Transgenders. 
• The team members can be psychologists, guest relations, vice presidents, dermatologists, gynaecologists, OPD nurses, gastroenterologists, medical directors, plastic surgeons, anaesthetists, craniofacial surgeons, OT nurses, and legal advisors.
• In transgender clinics, most of the surgeries include sex reassignment surgery, facial feminization surgery, breast augmentation surgery, mastectomy and larynx surgery.

Conclusion

Transgender Care and its psychiatric perspective are an emotionally challenging and daunting task for any transgender and gender diverse individuals. There are many routine psychological issues which are observed among these individuals in their daily routine. The process of exposure to the outside world can be a difficult and time-consuming task for many of them.

However, much progress has been made in recent years regarding Transgender Care such as the establishment of medical care centres, surgical equipment involvement in providing surgeries and spreading awareness for better care. Psychiatrists play a crucial role in taking care of trans people with mental illness and substance use disorders. The technological and medical advancements in healthcare has also helped improve the quality of life among the people of the transgender community.