Aug 312015
 
Psy_II

The Greek letter Psy is often used to symbolize psychology or the APA.

The American Psychological Association has released a 55-page document detailing guidelines for psychologists treating transgender and gender non-conforming individuals. To my knowledge, this is the first such document the APA has published. It’s a huge milestone in trans mental health care.

APA guidelines provide standards for both trainees and practicing psychologists on the expected conduct of psychologists. They’re used in both introductory and continuing education.

In this document, the APA lists out the following guidelines (note that TGNC stands for “transgender/gender non-conforming”):

  1. Psychologists understand that gender is a non‐binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.
  2. Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.
  3. Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.
  4. Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.
  5. Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well‐being of TGNC people.
  6. Psychologists strive to recognize the influence of institutional barriers on the lives of TGNC people and to assist in developing TGNC‐affirmative environments.
  7. Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well‐being of TGNC people.
  8. Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.
  9. Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.
  10. Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress.
  11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans‐affirmative care.
  12. Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.
  13. Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.
  14. Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.
  15. Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.
  16. Psychologists seek to prepare trainees in psychology to work competently with TGNC people.
This is all excellent.
There is a history of psychologists attempting to change gender identity through conversion therapy or other coercive means. The APA’s statement, in effect, states very strongly that attempts to change gender identity should not be attempted. Instead, the APA is embracing the ethical treatment of transgender people and of affirming transgender and gender non-conforming people.
Do these guidelines mean anything for you if you’re receiving therapy? Possibly. Talk with your therapist, whether you’re trans or cis, to make sure they’ve seen the updated guidelines. If you’re receiving therapy that is not within these guidelines, consider talking with your therapist about these guidelines or seeking another therapist.
And spread the word! The document itself is publicly available as a PDF.
Aug 242015
 

148px-Orange_ribbon.svgRecent reports have highlighted the frequency of non-suicidal self-injury among gender and sexual minorities. 41.9% of transgender people have self-injured. I was unable to find a percentage for cis lesbian, gay and bisexual people beyond the general report that the rate was “much higher”. Gender and sexual minority (GSM) youth are at particular risk, as are cis women.

So let’s take a quick look at non-suicidal self injury this week. What is it? Why do people do it? And what should those who currently self-injure, and their loved ones, know?

Non-suicidal self injury (NSSI) is a term that refers to deliberate attempts to cause oneself injury without intending suicide. The “without intending suicide” is the important bit there. This is a separate phenomenon from suicidality, though both suicidality and NSSI can come from the same psychological source. NSSI can take many forms, but cutting and burning are the most common. People who have higher levels of stress, such as GSMs, are at higher risk for NSSI. Transgender people may have an additional risk factor because of extreme body dysphoria.

To most who have never participated in NSSI, it can seem baffling. Why would a person do that to themselves? While everyone has different reasons, at core NSSI is about survival. Many use it to defuse overwhelming emotions. Emotional pain is just like physical pain in the brain, causing activation of the same areas. All pain causes the release of morphine-like chemicals in the brain which buffer the pain, causing the sensation of a “high”. By creating physical pain in reaction to emotional pain, the person doing the NSSI can regulate their own emotions and cope. Other people who do NSSI are attempting to focus. When the world seems far away or they feel numb, pain can help them to feel something and give something to concentrate on. Lastly, some people who do NSSI do so as a way to punish themselves, as a way of asserting control in a powerless situation, or to communicate their emotional pain….or for any number of other highly personal reasons.

NSSI is not an ideal way of coping with life’s stressors. It can be addictive. It’s easy to hurt oneself too much and accidentally attempt suicide or develop infection. Scars and NSSI behavior attract attention, limiting one’s ability to get or maintain a job. Over time it can permanently change a person’s responses to stress and pain.

NSSI is often misunderstood, even in psychology and medicine. Most psychologists and physicians have never experienced NSSI or been close to people who have, so they fail to understand the reasons for NSSI. Until the DSM-V, the only psychological diagnosis that applied was that of borderline personality disorder, which most people who do NSSI do not have.

It can be difficult for a person who self harms to get help. Psychologists and physicians are legally bound to report individuals who are at risk of harming themselves or others to the police. While necessary, it limits confidentiality and can harm trust. Some professionals require that a patient sign a “no self harm contract” before receiving any treatment. Not all patients are willing or able to sign such a contract. Physicians have a limited set of options for treatment: medications (which can take 4-6 weeks to begin to work), referral to a psychologist or psychiatrist, do some level of psychological intervention themselves, or admit the patient to the hospital. And then there’s the question of affordability, especially if you’re unable to hold a job because of the self injury.

Despite these barriers, psychological and medical professionals can be very helpful for people seeking to stop self-injuring. At bare minimum, having a psychologist or physician in the loop can help if a particular incident of self injury goes further than intended. NSSI is a coping strategy, and psychologists and physicians can be very helpful for the issues lying underneath self injury, whether that’s depression, post traumatic stress disorder, or just plain stress.

Lastly, it’s important to know that people can and do learn non-NSSI coping strategies and learn to be self-injury free.

If you want to learn more about non-suicidal self injury, I highly recommend this website. It’s old and the current version is broken, so that links off to the Wayback machine version. It’s still one of the best sites written by people who intimately understand self injury and work to provide information and help others. For a modern alternative, this website also has support forums.

 

 

Mar 162015
 

170px-Rod_of_Asclepius2.svgBeing a gender or sexual minority (GSM) is not only difficulty and tricky for patients — it can also be a challenge for medical providers. Medicine can be a particularly conservative field, depending on location and specialty. Lives are, after all, often at stake.

Despite recent advances it appears that some 40% of lesbian, gay and bisexual medical students are hiding their sexual minority status in medical school. Among transgender medical students, 70% were hiding their identity. All because of fear of discrimination.

That fear has been, and still is, warranted. From medical providers transitioning and losing their practices, to medical students losing their residency slots, to LGBT health student organizations fighting to exist, LGBT providers face similar discrimination as our patients.  Similar happens for other gender and sexual minority health care providers, though we lack statistics. At a meeting of kink-identified mental health care providers, one attendee noted a high level of vulnerability for the clinicians. Being “outed” could lose them their jobs or even trigger legal action.

To some extent, discretion among health care providers is warranted. Most people don’t want to know about their clinician’s (or coworker’s) personal lives. And most GSM providers don’t actually want to share those most intimate details. It’s where the line is that can be distressing — how much information is too much? Can I discuss my wife when other women clinicians are discussing their husbands? How exactly do you notify your fellow clinicians or patients about a change in gender pronouns or name? How can a clinician use information gained from intimate encounters to help patients, without revealing too much? It’s a balance we constantly seek. Sometimes mentors are there and can help. Other times we figure it out as we go along.

Yet we bring a lot to the table, as minorities. Like many racial and ethnic minorities, there are pressures and issues that affect GSM people more than the majorities. We bring that knowledge with us to the research we choose to perform, the communities we participate in, and each and every patient encounter.

We as clinicians and future clinicians need to have the support in order to be appropriately open about our gender and sexual minority status. Our patients and clients must know they can be safe and honest with us so they can receive the most complete and respectful care possible.

Some progress has been made already. There’s an association for LGBT medical professionals. There’s an association for kink psychological research. There’s an association for transgender health. All of which allow student members and provide mentoring. Many other organizations exist too. Some US medical schools are working with their students to provide a safe and welcoming environment where these issues can be explored. The American Association of Medical Colleges recently launched a program to enhance education surrounding LGBT and intersex health care. The American Medical Association also has an LGBT Advisory committee.

I’m proud to say that my medical school has been accepting and supportive of its gender and sexual minority patients, and that clinics in the area of my medical school are seeking to expand their care to be more inclusive of LGBT patients. Support exists for both those seeking medical care, and those seeking to provide that care. It’s only the beginning.

Aug 022014
 
Rural vs Non-rural

Rural vs Non-rural

This study used a convenience sample of transgender individuals and compared mental health factors between trans people living in rural and non-rural areas in the United States.

Why would health and health care differ between rural and suburban or urban trans people? A number of possible factors, including…

  • Transportation issues.
  • Overall difficulty accessing health care. Fewer physicians, fewer hospitals. Few big research or teaching hospitals.
  • Possibly less social support for healthy lifestyles. Depending on the community, support of a healthy lifestyle may be less. Rates of tobacco use, alcohol drinking may be high and access to exercise and a fruit/vegetable-focused diet may be low
  • Less accepting physicians. Rural areas are traditionally more socially conservative, possibly resulting in higher rates of transphobia. Open-minded physicians may not have the resources to learn about transgender health care, and access to specialists is limited in rural areas
  • Smaller minority communities. With a smaller population, and transportation time, it’s much harder to form a supportive LGBT or trans community. Social support and information sharing may be very limited.

The vast majority of transgender health centers are in urban areas including San Francisco, Los Angeles, New York City, Seattle, Boston, Washington DC, and Philadelphia. Resources in places like the middle of rural New Mexico are few. But that doesn’t mean people in such rural places don’t need care too.

This research used the internet, advertising on mailing lists, journals, and forums, to recruit and survey trans people in all areas. They ended up with a very large sample for a trans study: 1,229 people! What determined whether a person lived in a rural or non-rural area? The participants self-selected an option – and if they selected “rural” or “small town” for their location they were classified into “rural”. Other options (suburban and urban) were classified “non-rural”.

What did they measure? Basic demographics, substance use, mental health (including anxiety, depression, somatization, and self-esteem), and sexual risk behaviors. That last one – sexual risk behaviors – was specifically narrow, focusing only on protected vs unprotected penetration with a penis.

The results were fairly clear.

For trans women, there was no different in mental health between rural women and non-rural women. But trans men were statistically significantly more likely to have depressive or anxiety symptoms, low self-esteem, and other similar mental health problems if they were rural than if they weren’t rural.

There were no significant differences in substance use for either trans men or trans women. There were no differences in sexual risk behavior either.

Some interesting, and some disturbing, statistics that came out of this:

  • 25-27% of trans women reported a previous suicide attempt vs 38-40% of trans men.
  • 7-10% of all trans people in the study reported binge drinking alcohol in the past 3 months. 7-13% used an illicit substance other than marijuana in that same time frame.
  • 42-45% of trans women reported unprotected penile sex with either a primary or non-primary partner, vs 16-21% of trans men (in the past 3 months)

This study isn’t perfect. It was internet-based and used a convenience sample, so it may not reflect the larger trans population. It also used a broad definition for transgender at times, including those who cross dress for reasons other than gender identity. The fact that it was internet-based means that people who do not use computers or have access to the internet weren’t included. Still, it was the first of its time and its methods were fairly sound given these restrictions.

So what can we conclude?

  • First, something that we knew before: Trans people are in need of compassionate, open-minded mental health care and medical care no matter where they live.
  • Second: That trans men living in rural ares may be faring worse than their urban and suburban brothers.
  • Third: That rates of suicide are still unacceptably high for all trans people
  • Fourth: That trans people, especially trans women, are still at unacceptably high risk for HIV and other STDs via unprotected sexual contact.

What can we do about all of this?

Rural health care is a challenge for both physical and mental health. Telemedicine options continue to be in development. Education and outreach efforts must continue within trans communities. Those who work in physical and mental health, whether rural or urban, must understand that transgender populations face specific stressors and have specific health needs. Efforts to educate all providers, such as WPATH’s mailing list and Trans Line, must continue to be available and probably should expand.

This paper was published in the Journal of Homosexuality and is publicly available.

Apr 162014
 

One of the premier medical journals, the New England Journal of Medicine, regularly has perspective/opinion pieces. For a pre-med like me, they can be some of the most valuable pages in the journal — they can be windows into medical practice, public policy and the study and practice of medicine. I read them regularly, since my wife got me a subscription to NEJM. Most aren’t related to gender and sexual minority health, so I haven’t addressed them here much. But in the April 10th edition of NEJM, a treasure! Gilbert Gonzales did a good summary of the intersection between same-sex marriage and health.

Many health journals, including NEJM, tend to live behind a pay wall. This particular article, thankfully, is not. But in the interests of public knowledge and discourse, I wanted to summarize some of the interesting points in this article. A heads up: this is a distinctly United States-focused article.

  • Despite recent advances, roughly 60% of the US population lives in a state that prohibits same-sex marriage
  • There are significant health disparities between LGBT and heterosexual/cisgender people, as shown by the 2011 Institute of Medicine report on LGBT health (which I summarized in 3 parts at the time).
  • Discriminatory environments lead to poorer health outcomes. Example: LGBT people in states that ban same-sex marriage have higher rates of depression, anxiety, and alcohol use than straight/cis people in the same states. By the same token, states where same-sex marriage (e.g., MA and CA) was legalized show a drop in mental health care visits for some GLBT people (e.g., gay men).
  • Legalizing same-sex marriage improves access to health insurance for both same-sex spouses and children of same-sex parents.
  • The Affordable Care Act prohibits insurance companies from denying health insurance coverage because of sexual orientation, transgender identity, or pre-existing conditions like HIV.
  • The recent decision on DOMA (United States v Windsor) means couples in a same-sex marriage get taxed like other married couples. This lowers the tax burden of health care costs and health insurance.
  • Health benefits of same-sex marriage should be included in discussion of marriage equality.

All good things to point out, and good to see in such a mainstream medical journal.

We’re lucky enough that the NEJM has decided to have this article be open access. So if you can, read it to form your own opinions!

And as always…  Stay healthy, stay safe, and have fun!