Hello and welcome. I'm Dr. Donna Rowland, Director of the Psychiatric Mental Health Nurse Practitioner Program at UT Austin and clinical nurse expert for SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, An Affirming Psychopharmacological Approach to the Transgender and Non-Binary Client. Next. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until September 27th. Next. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF file. Next. Please feel free to submit your questions throughout the presentation by typing them into the question area. This is found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next. Now I'd like to introduce you to the faculty for today's webinar, Dr. Kimberly Chomey. Kimberly Chomey is a psychiatrist practicing in Austin and originally from Texas. They have had academic positions, most notably at McGovern and UT Austin Dell Medical School, as well as UT Southwestern, UT Medical Branch Galveston, Texas A&M Medical School, and UT Austin School of Nursing. They've worked in private outpatient practice and inpatient general psychiatry, specialized in inpatient care for mood disorders, PTSD, and personality disorders, as well as IOP and PHP settings, where they trained in and employed DBT skills. They have an appreciation for working with LGBTQIA plus clients, neurodivergent clients, treatment-resistant depression, PTSD, and personality disorders. They currently hold adjunct assistant professorship with UT Austin Dell Medical School and practice telepsychiatry, and they're the medical director of locally-based PRISM integrated care. Dr. Chomey, thank you for leading today's webinar. Thank you, Donna. I really appreciate that. So, just to get started, I don't have any disclosures to kind of note at this time. So, my name is Kim Chomey. I am a psychiatrist in Austin, Texas. I am also transgender, and I use they-he pronouns. All right. So, our learning objectives for today is that we're going to kind of like look at terms such as transgender, gender non-conforming, non-binary. Perhaps some of you have heard some of these terms before when working with your clients. We're also going to talk about other terms that are necessary in the treatment of patients that are identifying thusly. The treatment of patients that are identifying thusly. We're also going to identify symptoms of gender dysphoria according to the DSM-5. We're going to look at also maybe some of the drawbacks of that diagnosis and how it is implemented in the medical treatment of folks that are transgender, and then we're also going to look at differential diagnosis of gender dysphoria symptoms. There is a tendency for folks who are transgender because of intersectional difficulties, multiple issues, being transgender in our society. They oftentimes do have increased risk to affective disorders, anxiety, and other diagnoses. And then what we're going to do is talk about the WPATH guidelines for mental health professionals in taking care of transgender, non-binary, and gender non-conforming individuals as well. I'm welcoming all questions and just let us know. We have in the app, you're able to make some comments and questions. If you want to save those to the end too, we're happy to kind of answer those for you. All right. So just to kind of understand a little bit about the population that you'll be serving, 1.6% of US adults identify as trans or non-binary. Oftentimes, people think that that number is actually quite a bit smaller. And that number has grown in recent years. And we think that the reason why that is, is because there is more kind of online education, more access to resources for folks to kind of understand and explore their own gender and how that kind of applies to them. The reason why we kind of think that that might be the case is that as we look at folks ages 18 to 29, we see more of them more likely to identify as gender non-conforming than, or like other than assigned at birth compared to other populations. And so I think probably many of you are aware that we see that in what we would call the Gen Z population, as well as the millennial population. And it is the highest among that Gen Z population of people. However, that doesn't necessarily, because there are some biases around that, some people feel like that this is like some sort of new modern kind of fad, or that it applies to kind of like popular culture and the assimilation of LGBTQ kind of images within that culture. However, what we really actually see is that this is probably due to kind of more access to information about what being trans and non-binary and gender non-conforming are. Trans and non-binary individuals compose a geographically, ethnically, and racially diverse group. And I think it's really important to kind of keep that in mind. I think one of the biggest biases that we have within medicine and outside of medicine is that folks who are transgender are in more urban areas. And while that may kind of be kind of a beacon for folks, because they can have more resources in those areas, if somebody doesn't have access to moving to one of those areas, they're tied to family in a geographically rural location, then you're going to see folks in all walks of life that are going to identify as trans and non-binary. The other assumption is, is that folks that are gender non-binary, transgender or gender non-binary, that those folks don't live in the South. Those folks have a tendency to live in more like Northern locations. That is very untrue. Actually, what we see is that a majority of people that identify as transgender actually do live in the South and Southwest. And so that's something to kind of keep in mind that just because you might be in an area that is not necessarily very liberal or kind of accepting of those populations, that doesn't necessarily mean you're not going to encounter them. In fact, it gives you the opportunity to kind of like be a beacon for those folks as they try to encounter care that's germane to them. It's also a very ethnically diverse population. What we know is, is that folks that are transgender come from all walks of life and from all localities. And it is something to kind of keep in mind as you kind of are looking at intersectional issues for folks, because being transgender is something that is very difficult within our society. And when you kind of look at other things intersectionally, it's important to kind of like multiply that for your client. And it is a very racially diverse group as well. Again, kind of stating back to that, just keeping in mind that you're working with a very diverse group and your clientele. Transgender children and adolescents are a very vulnerable group politically. Currently in the United States, there are 240 bills that have been introduced that would impact them directly. And what that means is, is like bills that would prevent them from treating their gender dysphoria, preventing their parents from doing so. Such as my state, Texas, actually punishing their parents if they are caught doing so. And this also brings into bathroom bills about whether or not children are allowed to use a bathroom that is identified with their gender, not their sex at birth. And then also the ability to play sports. Sports and physical activity are something that we know within our field are very vital for the health and well-being of somebody's state of mind. And as well as their growing self-esteem. And to kind of deprive children of that because they are trans is very, very difficult and is damaging. It is also very difficult for children to kind of see this and to know that there are these types of arguments that are going on around them politically. It is something that we have been able to kind of tie to increasing risks of anxiety, depression, suicidality in this population. The other thing to kind of keep in mind is trans elders. We have this now group of trans elders that are visible. There've always been trans elders, just to be clear. But we have more visible trans elders and that they have their own issues. They have increased risks of health and disability issues compared to cisgender, same age people. And they also have to contend with finding housing like retirement homes and things like that, that are going to be germane to them and be fair to them. And so that's something to kind of keep in mind as you're like taking care of these folks. All right. So just to kind of give you a few definitions, and this is not extensive. I think it is a nice place to start off, but I think that this is something that I think there's always the ability to build on. And within the community, we are very clear about making sure that there are as many definitions as possible. So people can identify themselves thusly. There has been historically a lack of the ability for people to name their feelings within the LGBTQIA community. And that's the reason why we have as many definitions as we do. And it's so that we can have people feel like they're validated within that community. So when you talk about sex, it refers to what a child is assigned at birth. And even in this definition, I kind of want to show for you that usually we see male and female. That leaves out the incredible intersex community as well, who maybe are born with ambiguous genitalia and oftentimes get assigned male or female based on the outward appearance of those genitalia, maybe on genetics, but it may or may not actually coincide with how they feel about themselves. And this is purely based on external anatomy. As we know, genetics doesn't necessarily line up with external anatomy. And so that's something to kind of keep in mind. When we talk about gender, what that means is, is that it's the behavioral, cultural, or psychological traits that are related to sex. And that is a very kind of dry definition. But what that means is, is that sometimes people will actually identify with some of those aspects that don't necessarily align with their sex assigned at birth. And so those two things are uncoupled and they are not necessarily coming together. I mean, oftentimes they are, the majority of the population is cisgender, but it does need, it does stand to kind of say that those two definitions do not necessarily flow together. And when we talk about gender expression, that's a little bit different than gender because oftentimes somebody can kind of talk about their gender, but their gender expression may not necessarily completely align with that. But that's okay. What that means is, is that you might have somebody who identifies their gender as being a woman that likes to dress a bit more masculine. That does not necessarily mean that that person is transgender. That only implies that they have a more masculine gender expression. And so you don't necessarily get to use somebody's gender expression as a way of informing whether or not this person is transgender. In fact, that can be really, the looks can be deceiving. And the best way to kind of ask if your patient is transgender is to ask them if they are transgender and not to make assumptions based on gender expression. We also see within gender expression, sometimes pronouns kind of come up, mannerisms, things like that. But again, it is not the same as somebody's identified gender. Sexual orientation. That is a very complicated thing because I think that we've done within our community a very effective job of decoupling the idea that sexual orientation and gender are the same thing. And that comes from that historical look of like not having definitions to kind of like define people as clearly as possible. And oftentimes sexual orientation did get lumped together with gender expression or gender. And so what sexual orientation is, is attraction to an individual. And it's defined by gender or gender expression. What we know about that is, is that they are two different things, gender and sexual orientation, but they can influence one another. And they sometimes can change depending on how one or the other changes. Somebody who is transgender is somebody who has a gender identity that's different than that, that was assigned at birth. And to be clear within that community, you have folks that are transgender who identify as trans men or trans masculine, trans women or trans feminine. But you also have the great community who may or may not say that they're part of the transgender community, depending on their own personal beliefs. Folks that are non-binary, gender non-conforming, or gender queer. And we're going to talk more about that too. But they don't neatly correspond to male or female. And they also take up space within the transgender community. But again, some folks who are non-binary, gender non-conforming, or gender queer don't necessarily ascribe to being transgender. And so it's clear to know that that's something that is a part of our community. But at the same time, it may or may not necessarily be defined under that same flag. And then for folks that are cisgender, that means that your gender identity is the same as that that was assigned at birth. And so that is the majority of the population. And you will hear me use cisgender. I think it's very important too, when you're talking about working with transgender clients and non-binary clients to use the word cisgender. Because if you don't, what that implies is that being transgender or being non-binary or gender non-conforming is somehow different than quote unquote normal. And so when you have a word that is neutral to describe folks that are cisgender, then it normalizes the experience of the transgender individual, making it easier for them to kind of access care to you. All right. So when we talk about dysphoria, it is described in the DSM-5. And it has changed compared to the DSM-4, where it was gender identity disorder. And what is important to kind of understand here is a couple of things, is that there is within psychiatry and within medicine, a need to kind of medicalize certain things in order to lend it credence or lend it kind of like quote unquote respectability. However, sometimes some of the medicalized model does not necessarily apply directly to the transgender experience. And so while we talk about dysphoria, and while we try to make sure that we give access to care for folks based on that dysphoria experience, we also want to make sure that you're aware of something else that happens. When somebody is able to access their gender identity in a way that is meaningful to them, that you have a gender euphoria as well. And that is not the euphoria of mania or anything like that, but it is a very positive, incredible experience where you get to kind of present in the world the way that you want. And so I think it's important to know that there are negative things that come from not being able to be yourself, but there are also positive things that come from being able to be yourself. And I think that that's a very important thing to keep in mind. The other thing too that comes with the medicalization of treating transgender folks is that there is the assumption that there is this kind of streamlined algorithmic pathway for how people are going to access care. And that's not necessarily accurate or appropriate for every transgender individual. In fact, the transgender experience is something that you get to kind of make for yourself. And some people may be able to and want to access hormonal treatments or other types of medical treatments. They may want to access surgical treatments for that to kind of help them feel more aligned, or they may not. So the thing that we sometimes see, and I've sometimes heard some folks within medicine or within mental health communities say is like, you know, it's like a transgender person is defined by the experience of their process through the medical kind of process of becoming trans. And that's actually not accurate. Somebody is trans if they say they're trans. So when you look at the diagnosis of dysphoria, you have incongruence. So that means that you have a difference between, you know, what you're experiencing as your gender and what you were assigned at birth. A desire to be rid of sex characteristics that feel incongruent to you. And they may be all of those things that come with your kind of like sex assigned at birth, or it may be some of those things. And it is complex depending on, you know, if a person identifies as trans, if they identify as non-binary or gender non-conforming. And so that's something that gets to be defined by that person. Okay. It's not defined necessarily by a quantity of those symptoms for us to kind of manage. The desire for sex characteristics of another gender, or the desire to be another gender, or the desire to be treated as another gender, or the conviction that they have feelings and reactions of another gender. And as you can see, as the DSM-5 kind of came out in 2011 to 2013, I think it was being worked on, even then there was that lack of wording for folks that are gender non-conforming or non-binary. And it has this kind of binary that's already written into the DSM. And so I think it's important to kind of, as you look at this, you kind of be flexible in the way that you're thinking about and conceiving this. Per the DSM-5, there's a six month duration. And that's something that comes up for people who are seeking out gender care, especially surgical forms of gender care, because those folks oftentimes are required to prove that they have been treated for gender dysphoria for six months duration prior to being able to getting treatments for their gender dysphoria. And so sometimes this means that it can be a real barrier to care for folks. It's oftentimes very expensive to see a mental health practitioner. Sometimes if you're in a rural area, you may not have access to it. Sometimes you may feel like there's not a qualified individual who can kind of understand your experience. And so this is actually a barrier to care. And it's something to kind of keep in mind as you're treating your patients is to be aware that, you know, even as this exists, you know, gender dysphoria is something that a time limit on is not necessarily something that you should be very, very rigid around. Gender dysphoria implies that is not explicit that gender dysphoria is not internally felt, but it's externally applied. And what that means is that oftentimes people feel that dysphoria not only because of what their body looks like and how they may or may not feel that their body aligns with how they feel, but also with how they're treated in society. So if you are a transgender individual or you're non-binary and someone around you, like your family, your school, your political parties that govern you, insist on using language that is derogatory, or kind of insist that you're not allowed to kind of use pronouns that are appropriate to you, that can also cause that dysphoria to occur. And so it's important to understand that it's not just an internal process. It's something that is kind of brought to people from the outside as well, that they experienced from others and they experienced from society. And again, I just want to reiterate, this is a good example of medicalization of identity. And we have to kind of understand that there are historical ties to medical oppression. Take for instance, right now, there are parties within the United Kingdom who are looking at and understanding, and I'm going to bring up later on, the fact that there is a confluence between folks who are diagnosed as autistic and people who are gender non-conforming, non-binary or transgender. And they're using that as a way to kind of say that those folks should not be able to access gender care because they have a quote unquote mental health or developmental condition that would preclude them from being able to make that decision about themselves. And so while we look at and understand that medicalization is kind of a way in the past that we've allowed people to get access to care and kind of lend credence to what they're going through, there can be that kind of backlash around it that it can actually cause oppression. All right. So when you're looking at the treatment for gender dysphoria, it's gender confirming care. I mean, that's simple. I mean, like you will see in certain circles that exist, they're oftentimes politically or maybe sometimes spiritually motivated that the treatment for gender dysphoria is the types of therapy that change people's mind around their gender, maybe kind of give them like kind of opportunities to explore other gender expressions, etc. What we know about that is that it doesn't work. In fact, it can be very traumatizing for folks that go through that. And it's important to kind of understand that that is not the standard of care for the treatment of folks with gender dysphoria. So when we talk about gender confirming care, there are multiple things that kind of go into this. And so it's nice to kind of work with a multidisciplinary group so that we can kind of understand what's important from different disciplines in this care. So psychotherapy does play a huge role for folks that are experiencing gender dysphoria to allow them to explore kind of openly, you know, how they want to kind of be in the world, how they want to kind of exist, what kind of pronouns they want to use, how they're going to reveal this information to family, friends, if they're going to. The question sometimes is not only are you transgender, but or non-binary, or the question can be, are you going to express it? Sometimes that is also a very fraught kind of question for folks. And so I mean, psychotherapy plays a huge role in the actualization of what somebody identifying themselves as transgender or non-binary is going to look like, what their life is going to feel like for them. The other important thing, and we have a lot of data on this about how effective it is for treating gender dysphoria is gender confirming medications or HRT. I should say HRT plus, because we're not just talking about hormones, we're talking about some other things as well. But we know that the access to gender confirming medications can be incredibly positive for folks with gender dysphoria if they so choose to. Not everybody who, again, identifies as anything other than cisgender wants to kind of take any type of medical treatment. It's a very, very unique path for each individual. There is also the question of surgery, which we within the community kind of designate as top or bottom surgery. Those surgeries are meant to kind of align the genitals or the chest with something that appears more in line with your own gender presentation and gender identity. And so that is also something that comes up. And again, that gender dysphoria diagnosis is very important in surgery because insurance that is able to pay for this oftentimes wants that diagnosis and they are very kind of stringent around that six-month window. The other thing to kind of keep in mind is speech therapy. Speech therapy plays a huge role for both trans men and trans masculine people and trans women and trans feminine people to kind of be able to coach people around changing the timbre of their voice, how deep or how high the pitch of their voice is, and kind of train them around also the kind of things that typify more feminine or masculine speech. And so they play a huge role in this. And there are other types of disciplines as well outside of medicine that also play a huge role. The type of care that we provide at the place where I work at PRISM is a multidisciplinary kind of approach where we also kind of keep in mind that kind of engaging somebody's body physically is also a very important thing. So finding people who may be coaches or kind of trauma-informed yoga specialists who can kind of like help in that process is also an important thing. Again, I'm going to kind of like reiterate that there is no one specific path to transition. There is no one, have you had this specific surgery? Have you done this specific treatment? It's different for everyone. And the only thing that defines a transgender person is whether or not that individual identifies themselves thusly. And it's important to keep that in mind, even if there is like some dissonance around that, whether there's some bias around what your feelings or thoughts are about somebody's presentation, the only important thing in treating a transgender or gender non-conforming or non-binary person is whether or not they have identified themselves thusly. The other thing that kind of comes up here and it's very important to understand is that there is the WHO standard of care versus what is called the informed consent model. And so the WHO standard of care basically wants a person to be identified as gender dysphoric for that period of time to be in some sort of like kind of access to mental health care where that is an ongoing process. Whereas the informed consent model, which is something that is more talked about in WPATH and other kind of guidelines, is that a person says they're trans, you know, they're having this experience. What you can do is actually give them the information they need to make informed like decisions around treatment for being trans after knowing the risks and benefits. And after they have been informed of that, allowing them the autonomy to be able to make that decision, which is much more respectful and it shows a high level of engagement. And sometimes people wonder or worry that if somebody is going into this informed consent model, surely that means that, you know, I'll allow a diagnosis of gender dysphoria. What if somebody changes their mind? Sometimes people do. That is very rare. Most people who get involved in informed consent clinic and start getting gender care through that clinic actually say that they have a high rate of satisfaction with that kind of care and stay with it and are able to kind of make decisions and feel good about that. And so just looking at that, that is the standard of care for many clinics in the United States. All right. So this talk is specifically about psychopharmacology and the trans or non-binary client. And I think it's important to kind of like bring that up again, because you're noticing that I'm talking about a lot of things that don't necessarily have to do with psychopharmacology. And I think that's important to note because there are some known issues that kind of come up with psychopharmacology and hormone treatments, but there are not that many. And it is not something that provides a clear barrier to care. Oftentimes people worry and are concerned that hormones might be something that like, oh, how am I going to treat this person with psychopharmacological treatments if they're on these hormones? And so it's important to kind of know that there are some things that we understand about, especially estrogen, and that we can kind of like make allowances around that. And we're very aware of like the tried and true troublemakers within psychopharmacology that can kind of like cause some changes at the P453A4 system, like about fluvoxamine. And there are some other things that kind of come up, but I think the most important thing is that there's not really any contraindications to any type of treatment for folks that are in gender care with hormone replacement. And so I think that that's going to be my overriding thing that I just want to get into. So when we talk about feminizing medications, in the past that would have been estradiol and progesterone. We don't typically see progesterone being given to trans women now. In fact, it's contraindicated. Usually this only includes estradiol. And when we think about how estradiol is dosed, most often you see oral, transdermal, IM, and sub-Q routes of administration. A lot of people use transdermal because it is very comfortable to use. We usually see within these populations, within the trans community, using non-oral routes because you're looking at a medication that's going to be used for a long period of time. You don't have to worry about the concerns of first pass metabolism and consequently higher dose medications. Because if you got first pass, you're going to have to give higher doses of medicine. And sometimes those higher doses of oral medications can be associated with more embolic events. And so that's something you have to keep in mind for both estrogen and testosterone is to increase risk of embolic events. And so using non-oral routes are the most common. And that's what's most recommended for folks. When we think about estradiol, it does a lot as far as inducing or inhibiting multiple P450 systems. And so just kind of knowing and understanding that, we know that there are multiple medications influenced by that. Many of them are able to be tested by blood level. And so that's something that kind of takes away that worry and concern as well. So when you think about 2A6, you think about valproic acid is something that is a substrate of 2A6. It induces 2A6. And so it can kind of decrease valproic acid levels. However, that's something that you can check out on a VPA test. If somebody is on Depakote or Depakote ER, you can just make sure that their levels are looking good. So that's not something that's going to be contraindicated. 1A2 inhibitor. So you can see that blood estrogen levels can be increased when estradiol is given with fluvoxamine because 1A2 is one of the P450 system that works with fluvoxamine in addition to 3A4. And it is a 1A2 inhibitor. Estradiol also might increase blood levels of certain TCAs. It might increase olanzapine, haldol, clozapine, or duloxetine. And so, you know, with those medications, I would recommend monitoring like side effects, kind of monitoring like how a person is doing with that. But there isn't necessarily any indications that you shouldn't use those medications. There isn't any indication that you should necessarily immediately decrease the dosages of those medications. But it's one of those things that you would just kind of continue to monitor and see how people are responding to those medications while they're also in HRT treatment for their gender care. 2C19 inhibitor. So knowing that fluoxetine and fluvoxamine are also inhibitors. And then carbamazepine is an inducer. Again, you're going to have like your kind of old known actors. So carbamazepine comes up here. And for folks who are still prescribing carbamazepine for mood stabilization, just know that you're going to be able to kind of monitor that. And if you're prescribing carbamazepine, you should be monitoring blood levels because it is an autoinducer and it does play with a lot of other medications. The one most salient thing I would say is the 3A4 substrate. And it is the metabolism can be inhibited by fluvoxamine. And so that is something to keep in mind. So if you have a patient who is trans and who is taking estrogen, it might be worthwhile when you're kind of going through the medication kind of algorithms for the treatment of like OCD, that maybe you kind of keep in mind that there are other medications that can be used first. If a person does need fluvoxamine and they have a known positive treatment response to fluvoxamine though, there is no problem with giving fluvoxamine. It would just be worthwhile to kind of like monitor that and maybe kind of let the primary care doctors, typically it could be an OB-GYN that's prescribing these types of medications. It could be multiple types of doctors. Just let them know that you are starting them on fluvoxamine and that they may need to kind of like monitor effects. And that patient is going to be able to kind of help in that too, because the patient is the one who's going to be observing the effects of their estrogen. And they're going to be able to kind of give feedback thusly. It is also a weak 2D6 inducer with likely little effect on drugs through this pathway. Now, the other thing that comes up, and this is outside of the P450 system, is that we know that estradiol increases liver glucuronidation, which we need to kind of keep in mind for folks that take lamotrigine. So you know that that increases that lamotrigine clearance 2.1 fold. And so kind of making sure that that person is on enough lamotrigine in order to have a clinically positive effect from it is going to be an important thing to remember. The other types of medications we use for feminizing treatments are spironolactone and finasteride. And so with spironolactone, we know it is an autoinducer of 3A4. Again, 3A4 is going to be the big salient P450 system to keep in mind. Its active metabolite is an inhibitor of 3A4 as well. And it's known to induce glucuronidation, and it can reduce availability of oral estradiol due to its effects. And so it is something to kind of keep in mind. However, spironolactone has been given in the treatment algorithm for trans-feminine people, like with estrogen, for a long period of time. We know they play well together. This is probably more academic unknown than anything else. And so no worries around that. And then finasteride, again, is metabolized through 3A4. And so aflavoxamine may increase its availability. In the case of trans-feminine people, this probably doesn't have too much of a negative effect as finasteride is used to kind of like block DHT, allow them to have less hair loss, and have more feminizing effects. And so it's something to kind of keep in mind. There is one thing I would say that if finasteride becomes more available within the bloodstream, this could affect the sex drive of folks who are trans-feminine because DHT can increase, like it is linked to somebody's libido. And if somebody has a declining libido, that could be due to their finasteride. Not a lot of studies have really looked at to see whether or not it's going to affect that population of transgender folks thusly. All right. So masculinizing medication is a little bit simpler. So we have testosterone. It is usually given IM, sub-Q, or transdermal. There are intranasal forms of testosterone, but they're oftentimes prohibitively expensive for trans folks to utilize. It's, again, metabolized by 3A4. So the medication to watch, again, is fluvoxamine. And so, I mean, like that's going to be the one that kind of comes up for 3A4 when you're talking about psychopharmacological interventions. And we already talked about finasteride. So finasteride is also used for care of trans men. Oftentimes, once they start testosterone, male pattern baldness sets in, and that is oftentimes prescribed for folks to kind of offset male pattern baldness. So why are we talking about these medications and why they're important? It's important to kind of know about the symptoms of psychiatric conditions as well as psychiatric conditions that occur commonly within the trans community. So prevalence of mental health conditions are higher in trans folks. And so we see an increased occurrence of symptoms of anxiety, depression, and psychosis. And so that leaves aside like diagnoses per se, but we're just looking at those types of symptoms. And it is significantly different compared to cisgender folks. Presence of mental health conditions increase the risk of chronic medical morbidity, which we know that already within the cisgender population. But we know that intersectionally, if you are living in stress because of some sort of thing like being a trans person, being a person below the poverty line, which if you're trans, you are at an increased risk of being below poverty line. If you are a trans person who also happens to be an ethnic or racial minority, you have an increasing risk like just that stress of being in that experience of increasing your medical comorbidity. And so we also know that mental health conditions can kind of increase that, not only because it's a mental health condition itself, but just the biases and the difficulty of having a mental health condition can increase your risk of chronic medical comorbidity and vice versa. Transgender individuals have a two to three-fold increased hazard of suicide compared to cisgender individuals. And we see that that's higher in trans youth and young adults. The biggest predictors for increases in suicidal ideations in trans youth is whether or not they have supportive individuals in their life. And of course, that's going to mean most necessarily caregivers like parents, family members, siblings that are going to be supportive. But that also means caregivers outside of that. So folks that are treating them and seeing them and kind of trying to understand their suffering and what's going on with them and helping them with access to care. And we also know that a higher kind of like political agendas that might be aligned against folks receiving that type of care can also increase the risk for this population. So the Trevor Project is an ongoing project to kind of monitor LGBTQIA plus youth to kind of like, look at like mental health needs of that community. And what we know is, is that we have trends that are watched about suicide, depression, anxiety, that we can kind of watch and see. Now, unfortunately, I put this graph up here and I have to do the job of like telling you what the graph looks like before COVID. And what we see is, is that we see mostly a steady rate of these types of symptoms. These symptoms are higher than in cisgender matched populations. And then the other thing to kind of take away is, is that they were lower prior to COVID and the reason why is because a lot of times folks were kind of stuck at home with invalidating family members things like that that made it hard for them to kind of like feel like they could express themselves the way that they wanted to be. So just kind of keep in mind this is going to be your hazard for treating these folks and that's why it's important to treat these folks affirmatively. Studies that look at young trans folks receiving puberty blockers and youth show significant inverse association with lifetime suicidality. So that means that those folks have a like better mental health outcome in regards to suicidality. Indicators for increased suicide risk include a decreased sense of school belonging, emotional neglect from family, and internalized self-stigma. So those are the things you're going to be watching for. Familial rejection is the biggest predictor of attempted suicide in trans youth. Again, that is the biggest thing that you can kind of watch to kind of understand what's happening for attempted suicide and suicidal ideations in that population. So looking at disparities in minority stress, transgender folks face a lot of economic disparities. They live oftentimes in lower income areas. They have delayed medical care for financial reasons or they worry about they're going to be discriminated against and so they don't seek out care as readily as a cisgender person would. There are positive or negative legislative impacts on trans people's mental health in those states that these things are happening in. Chronic health conditions are increased in the trans community which increases intersectionality with disability and that's an important thing to keep in mind. For BIPOC trans people, studies show that most recount negative experiences in medical settings both for their racial and ethnic identity but also for their trans identity and oftentimes it's like they're looking for somebody who can affirm both and oftentimes come up short in one or the other sometimes in both areas and so that's something to kind of keep in mind and that also is a barrier to care for them because oftentimes they will not access care. Experiences intersectionally for BIPOC trans people are different than white trans people in medical settings and so it's important to know that that population specifically needs to be kind of looked to and understood and that any type of medical bias that we might hold individually or as part of a group that we practice within needs to be assessed and changed. The things that also come up within the trans community is that because there is that kind of minority stress, we know in minority stress populations people try to cope the best way they can and so we do have rates of increased excessive alcohol and cannabis use that are higher in trans folks than cis folks. Excessive alcohol and cannabis and other drugs are associated with increased gender dysphoria so that actually is something that is it's important to kind of assess and to kind of allow people to understand this like hey we know you're coping with this by using alcohol cannabis or other drugs but it may actually be kind of worsening some of your symptoms. Minority stress, dysphoria, community norms around substance also play a role in substance use and within the community broadly there is an increased kind of normalization of substance use because it is something that has been used to kind of allow people to feel less stress or strain and that's something that oftentimes needs to kind of be addressed when you're talking with somebody and kind of motivating them towards treatment means that you're going to have to be very non-judgmental and kind of understand where somebody's coming from. Compared to cisgender individuals, we're talking about autism now. This is a very interesting kind of subject. Transgender and gender diverse individuals have higher rates of autism spectrum and other neurodevelopmental diagnoses three to six percent more likely to be diagnosed and then for folks who don't carry that diagnosis they oftentimes score higher on measures of autistic traits and sensory sensitivity than cis individuals do and so people are studying right now we don't have a lot of conclusive evidence but we're seeing that there is a tie between being autistic and also being trans or non-binary and this is kind of fascinating area to kind of look at but also to understand again within that medicalized model people rush to judgment around this and feel like this allows people from making decisions around their gender presentation, their gender confirmation, just because they have a diagnosis of autism and that does not preclude a person from making that decision around themselves. It's something that should affirm them allowing them to kind of understand more about themselves but not get in the way of seeking treatment. So when you're doing your psychiatric exam for folks you're going to kind of keep in mind your suicide screening. This has to be germane to mitigating factors so it's like when you're going through this you know what is the family, what is the community, what are the supports that this person has, what financial kind of things are going on for this person, what housing options are going on for this person. Finding housing if you're a poor trans person is very very difficult and then access to health care. All of these things impact that suicide risk in very specific ways to the trans community. Self-injury screening. Self-injury is increased in this population and it is important to kind of know that it is linked to dysphoria and it is not necessarily linked to borderline personality disorder or other types of personality disorders known for self-injury. Those two things can coincide but there's not an increased risk for borderline personality disorder in being a trans person. Self-injury oftentimes has to do with you don't like the body that you're in and oftentimes that injury can kind of occur thusly. Substance use screenings as we talked about. Also eating disorder screening because it is an increased risk across the trans community for having some type of eating disorder. And then for assessments prior to gender care psychiatric diagnosis is not exclusionary. There is no diagnosis that excludes somebody from getting gender care and again gender care is a multidisciplinary phenomenon and so while you might have somebody who is floridly and and acutely psychotic that doesn't mean that you can't have good conversations with them about their gender but kind of wait for them to kind of improve in symptoms so that they can kind of like make decisions in an informed manner. What you're looking for is a patient who can make informed consent. There is no exclusionary diagnosis to the treatment of gender dysphoria. Remember statement letters for care are required for surgery and often pose barriers to care. Many therapists, many psychologists, and many folks in our field oftentimes will do these letters for folks knowing that they are a barrier to care and will kind of help folks out around that. That is an ethical kind of issue that everybody kind of has to kind of look at on their own and kind of like make decisions around but just know that that is something that will impact somebody's access to care. Advocate for your patient and find supports for their family. That is one of the biggest things again family support is a big predictor of somebody's mental health outcome and if you find supports for their family that kind of get the family back on board with the patient, help affirm the patient, you're going to do a tremendous good for your patient. The next thing I'm going to talk about and I'm going to be wrapping up pretty quickly is trans broken arm syndrome and this is the thing that folks in the trans community talk about all the time is that when you go into a doctor or you go into any practitioner and you say hey doc I think I broke my arm I fell off a ladder not feeling so good and the immediate thing that the practitioner comes back with is like so I understand you're trans can you tell me whether or not you've had surgery can you tell me whether or not you've done this that or something else none of those things impact the fact that this person has a broken arm has pain in their arm and oftentimes is a very off-putting phenomenon that occurs within the trans community and so it's important to know when you're treating your patient when is an appropriate time to talk about things when is not an appropriate time to do it and to kind of like understand that these folks are just like any other people who have other types of medical or psychiatric or mental health phenomena that come up that may or may not be related to being trans and that has to do in psychiatric care with you know the the rates of likelihood of somebody having bipolar anything else like that are going to be you know just as likely in the trans community it may or may not have anything to do with them being trans though and so kind of like keeping that in your mind when you're treating folks is an important thing the importance of access to gender affirmation is again that's the treatment for gender dysphoria so mental health visits for anxiety and depression are decreased with gender affirming surgeries prescriptions for antidepressants and anxiolytics are decreased once people start gender affirming surgeries and one of the populations that's been looked at the most are VA and carceral populations because we do see an over-representation of trans folks in those populations if you the prescribing of antidepressants anxiolytics and antipsychotics were decreased in trans women after starting gender affirming hormone treatments and so you can see that kind of that affirming care is something that impacts the type of care that you provide as a mental health practitioner so concept of cultural or medical humility is that you meet your patient where they are no judgment knowing that if you are a cis provider you do not know their experience if you are a trans provider if you're part of the lgbtq community you don't know an individual's experience and so it's important to kind of be able to listen to that lived experience and understand it the best you can without putting any bias upon it when you're practicing you should train all staff and respect to the approach of patients in a positive manner it's not just you it's everyone else that has to be trained thusly include affirming posters flags artwork and waiting areas in the exam area consider non-gendered bathrooms or tell your patient hey you know we have a male and female bathroom but i want you to know you can use whichever one is most comfortable to you to allow them to kind of like know that feels like a safe place where they get to exercise their autonomy become fluent in terminology there's some really good sources that i've listed here so that you can look at that when you're talking to your patients collect their chosen name their pronouns their gender identity and if it affects you sex assigned at birth and that's a very important thing i mean like you need to know whether or not a transmasculine individual needs to have a pap smear you need to know whether or not they need to have a breast exam or a mammogram and so it's important to kind of know that but not to kind of settle on that sex assigned at birth is like the most important thing use their chosen name and pronouns documentation is important when you have a lack of documentation in the chart about somebody's gender status it makes them invisible in a clinical setting it also is a potential health care miss so people don't see them and they are invisible when you're assessing quality of care when researching this population we have a paucity of data around this i feel very conflicted about this however because again there are certain political movements that may or may not disenfranchise people from making autonomous decisions about their gender care and so when you do kind of document it might be good to have a conversation with your patients about around documentation as well to kind of see what they're comfortable with and see what affects them so here's some clinical pearls and then i'll finish up transgender individuals are diverse they're part of all communities and present multiple care settings gender dysphoria standard of care hormones and other gender care medications confirming surgeries and supportive disciplines gender care medications pose no higher complexity of drug interaction than cisgender patients taking hormone treatments transgender patients have increased risk of suicidality disorder anxiety disorder eating disorder and there's a higher occurrence of autism in this in this community and there are numerous resources for medical professionals to improve quality of care provided to transgender clients so here's some resources for you the trevor project gives you resources on understanding how trans and lgbtq youth are impacted by mental health w path is going to give you your guidelines on how you can kind of set up your clinic and set up your practice and if you decide that you want to be involved in like trans care how to do that trans care ucsf also is an incredible website as well as fenway health both of those are leading websites and leading organizations in the trans community to kind of understand and treat folks thusly and then transjournalist.org if you're looking to kind of understand more about the terminology because sometimes cisgender folks not assuming that you all are cisgender but sometimes people get confused and flummoxed by these words this is a really good website to kind of understand those terms all right and then i have my sources and thank you very much i appreciate your time thank you for such an interesting presentation dr chomi before we shift into q a i'd like to take a moment to let you know that smi advisor is accessible from your mobile device use the smi advisor app to access resources education and upcoming events complete mental health reading skills and even submit questions directly to our team of us my advisor experts download the app at the website shown here okay we've got several questions we'll try to get through as many as we can first you have several comments that you might be able to see in the q a box i'm not sure if everyone is able to see that but really thanking you for naming gender euphoria being such an important aspect that hasn't been named historically also naming that the double the w path modeled care has been written primarily by cis providers and lastly thank you for naming minority stress okay the first question is a little bit long but i will read it out they need clarification so curious what this means and this was when you were explaining gender dysphoria in the dsm-5 so implies but is not explicit that gender dysphoria is not only internally felt but externally applied is the externally applied meaning external changes are applied to more align with the gender that they identify with or that the dysphoria is externalized i think that that's a great question and so what i was kind of meaning by that is is kind of both i mean like as you are in the world and you appear a certain way and you may not have been able to access gender confirming care it is going to be externally applied to your person but there are also things that are aside from that even as you kind of continue that process gender dysphoria can occur even as you're kind of confirming your care as you feel like you're aligning with things especially in the care of like gender non-conforming and non-binary folks feel very euphoric and feel very good about their care and how they look and how they appear but people still misunderstand them still kind of use negative pronouns that that don't that don't align with them and so i think it's important to know that that is i think you're answering your own question in a very good way i think both of those apply great thank you the next question um can you discuss one or two of the 240 bills that may affect transgender children or teens yeah so i can talk about specifically in in texas but this is also going on across the country montana iowa multiple states it may apply in some states to transgender adults in the case of missouri there is a bill that is proposed right now that disallows people from receiving gender care as an adult and that you are not able to kind of like get trans care and so that is number one is the limited access to trans care for youth the kind of penalty that is implied to parents or practice and or practitioners who allow those youth to kind of get care which is that's what's happening in the state i'm in right now texas kind of bringing people or entities on board to kind of like help kind of like modulate this like in the state of texas they have mobilized cps they have mobilized a couple of other entities as well to kind of like identify these individuals and their families which is particularly odious the bathroom bills that occur for restrooms in public schooling the current things that are going on in florida as far as the quote unquote don't say gay bill which kind of makes it harder for people to talk about their status which i mean isn't a very it's a very affirming thing to be able to talk about who you are as a youth and kind of find resources and find people who can kind of understand you the other thing that comes with that is like in a lot of these cases there's a necessary reporting by teachers or school counselors that these folks have to be outed to their parents whether or not their parents agree with them or not and then i think it's just an incredibly necessary thing that we talk about like trans and trans folks ability to be on athletic teams and participate in athletic activities we know that athletics and physical activity and youth is an incredible predictor of positive self-esteem that it helps improve that kind of mind-body connection and makes people feel like they're affirmed in themselves and feel proud of themselves and to disallow somebody that opportunity for misinformation's reason is also very negative as far as a predictor for mental health outcomes thank you and someone posted a comment that the aclu has a website on legislation around the country that's updated weekly that might be useful yeah i think it's very important right now because of the recent things that have happened with the supreme court that open up the idea that privatization of your kind of medical treatment is something that could be you know various varied by state to state and so right now you have to kind of watch day to day because things are currently changing and there is current legislation that's being proposed and there's going to be future legislation proposed great thank you and unfortunately we don't have time for any more questions i've got a few more wrap-up slides to go through but i encourage those of you who submitted a question we do have a discussion board community that i'll tell you about in a moment where you can get those we can get answers to the questions that you have see there it is it's showing on the screen now okay next so as my advisor is just one of many SAMHSA initiatives designed to help clinicians implement evidence-based care we encourage you to explore the resources available on the mental health addiction and prevention tcc's ttcs as well as the national center of excellence for eating disorders and the suicide prevention resource center these initiatives cover a broad range of topics from school-based mental health through the opioid epidemic to claim credit for participating in today's webinar you'll need to have met the requisite attendance threshold for your profession verification of attendance may take up to five minutes and then you'll be able to select next to advance to the complete to complete the program evaluation before claiming your credit please join us on august 4th as dr christopher palmer presents metabolism mental health and the ketogenic diet again this free webinar will be thursday august 4th from 3 to 4 pm eastern time thank you so much for joining us and until next time take care you

Dr. Kimberly Chomey

transgender

non-binary clients

gender dysphoria

gender-affirming care

hormone replacement therapy

gender-confirming surgeries

sensitive care

mental health conditions

limited access to care