Our profession has a number of obstacles to overcome in gaining the trust of transgender and gender non-conforming patients. We turn to this month’s expert, Jack Drescher, to better understand how to work with this population.
TCPR: Tell us about this new diagnosis, gender dysphoria, and what it means for patients.
Dr. Drescher: In DSM-IV, identification with the other gender was itself a mental disorder: gender identity disorder. That added stigma to a group that already experiences a stigmatized identity. That part is changed in DSM-5. The manual explicitly states that gender nonconformity in itself is not a mental disorder, but it retains a diagnosis for those for who experience distress and dysfunction due to incongruence between their experienced and assigned gender: gender dysphoria, without the word “disorder.”
TCPR: Why not take out the diagnosis altogether?
Dr. Drescher: The challenge we faced in the DSM-5 work group was to reduce stigma while maintaining access to care for patients who have a diagnosis of gender dysphoria. Removing the diagnosis completely would limit access to care for these patients, which includes access to endocrinology consultation and gender reassignment surgery. A different approach would be to remove the diagnosis from the manual of mental disorders but still include it as a medical condition. The World Health Organization has moved in that direction with ICD-11. There, the diagnosis is called “gender incongruence.” I am on the WHO work group that recommended moving that diagnosis from the chapter on mental disorders into a new chapter called “Conditions Related to Sexual Health.” The World Health Organization Assembly will vote on the entire ICD-11 revision in 2019.
TCPR: That makes sense, as the treatment for gender dysphoria has shifted into the medical realm with our endocrine and surgical colleagues. Those colleagues are also calling on us to screen patients before gender reassignment surgery. How should we fulfill that role?
Dr. Drescher: Historically, the role of psychiatrists and other mental health professionals in the treatment of transitioning patients was that of gatekeepers; that is, to make the determination about whether or not a patient should have access to care related to their gender identity. That is no longer the case regarding access to hormone therapy. However, there are many surgeons, for example, who are unwilling to accept a request for reassignment surgery without a mental health professional writing a letter. Many times, the surgeon may require that the letter be from a psychiatrist or mental health professional who knows the patient, has been working with the patient for some time, and can attest to the diagnosis of gender dysphoria. A surgeon might also request a second letter from an expert, who may not know the patient very well but has seen the patient in consultation. Today, it is the surgeons and some insurance companies who want mental health professionals to act as gatekeepers.
TCPR: What factors would steer you away from endorsing a patient’s request for gender reassignment surgery?
Dr. Drescher: It’s a challenging question. The issues are whether there seems to be a stable state of mind, whether the patient meets diagnostic criteria for gender dysphoria, and whether it seems reasonable to assume that the gender dysphoria would be improved with surgical treatment. For example, if a patient presents with psychosis, does gender dysphoria still persist when the patient is not in a psychotic state? One way to make that assessment is through treatment. For example, before recommending surgery, does something such as testosterone treatment relieve their anxiety and make them less dysphoric? And if so, does the patient still want a double mastectomy as part of the transitioning process?
TCPR: So, it sounds like a big part of the assessment is providing some reassurance to our surgical colleagues that this procedure is actually going to help the patient, and that the patient won’t be worse after the procedure and will be happy they had it?