Caring for Transgender Adults: Essentials for Behavioral Health Providers

Psychiatry plays a crucial role in Cleveland Clinic’s Transgender Surgery and Medicine Program, which provides comprehensive healthcare services to transgender adults seeking transition. Murat Altinay, MD, is a psychiatrist member of the program’s team and has developed specialty expertise in the care of transgender adults in Cleveland Clinic’s Center for Behavioral Health. He recently shared insights with Consult QD.

Q: What are the most common mental health issues among transgender adults?

Dr. Altinay: It’s a bit nuanced. Traditionally, the transgender population has been considered to have higher rates of depression, anxiety, suicide and substance abuse, including cigarette smoking and abuse of harder drugs. But when we look more carefully at the data in this population, we realize that mood disorders are overdiagnosed because untrained psychiatrists sometimes look at gender dysphoria symptoms and see them as depression or anxiety. When we follow these patients longitudinally, we often see that once they start getting transgender-specific transitional treatments, their depression and anxiety generally get better.

Q: How does management of transgender adults differ most notably from that of other adults?

Dr. Altinay: There’s a more comprehensive approach to care compared with other psychiatric patients. Beyond taking care of psychiatric comorbidities, we have to think about transgender-specific care, such as managing the physical side effects of hormones and connecting patients with surgeons for surgical consultation. It requires much coordination with other disciplines to make sure we understand these patients from medical, surgical and psychiatric standpoints and provide the best care.

Q: Can you elaborate on that interdisciplinary collaboration and coordination?

Dr. Altinay: Providers in our Transgender Surgery and Medicine Program meet on a regular basis to go over cases and make sure we’re on the same page. It helps us understand transgender people on multiple levels. They have different medical, surgical and psychiatric needs. If we don’t understand people on all these levels, we can create roadblocks. We want to make sure we’re helping and not making things more difficult for our transgender patients.

Q: What’s your advice to psychiatrists for making transgender patients feel welcome and comfortable in their clinics?

Dr. Altinay: My biggest recommendation is to be flexible and open. Too often physicians make certain assumptions based on how patients look and how they present themselves, and these assumption can cause us to make mistakes. Just because somebody presents in a traditional female presentation doesn’t mean they identify as female. That’s the key in gender care: We cannot assume anything. The goal is to start with open-ended questions and keep asking questions to understand the person in front of us.

Q: What might some of those open-ended questions be?

Dr. Altinay: Your chart says your name is so-and-so, but is there another name you prefer I use? If I were to ask about your gender identity, what would that be? If I were to ask about your sexual orientation, what would that be? I usually preface these questions by saying, “I’m going to ask some sensitive questions, but they aren’t necessarily nosey or intrusive. They will help me understand you better as a human being and avoid making mistakes in the future.” When I start with that, patients usually open up about their sexuality and gender.

Q: Do you have a typical intake approach when first establishing care with a transgender patient?

Dr. Altinay: I do essentially two assessments in one: I perform a complete gender identity assessment — exploring their life from a gender perspective from childhood through puberty, early adulthood, high school and college — then move onto a general psychiatric assessment.

Q: What’s your advice to clinicians treating patients with gender identification issues along with comorbid psychiatric conditions?

Dr. Altinay: First, they don’t have to solve all the patient’s problems at the first visit. Slow down, and break the consultation into two or three visits. The system pushes us to be fast and efficient and come up with answers right away. But with transgender care, taking our time helps us avoid mistakes and understand the patient better. Second, prioritize the patient’s problems. Sometimes patients present with many comorbidities, but gender dysphoria can be so severe that I won’t be able to treat other conditions until it is treated. I usually try to identify the most dire situation. Is bipolar disorder so bad that if I don’t treat that, I can’t get to gender dysphoria? Or is gender dysphoria running the show and preventing anything else from getting treated?

Q: Are there resources you recommend for psychiatrist colleagues who want to become more adept at caring for transgender adults?

Dr. Altinay: My colleagues and I give grand rounds and lectures, so that’s an option — reach out to us directly [altinam@ccf.org] and ask for recommendations. Secondly, the World Professional Association for Transgender Health (WPATH) offers basic training on how to assess, treat and diagnose transgender people. WPATH also publishes guidelines, and the new version of their guidelines (No. 8) is about to be published soon. WPATH is the best resource for guiding care of transgender people.