Transgender visibility during the past 5 years has reached an all-time high, as evidenced by increased media coverage, an upswing in clinical practice interest, and a moderate increase in transgender research funding dollars. Additionally, for the first time, the approach to the care of transgender youth has become a major part of the transgender care landscape. Now more than any other time in history, data indicating that the prevalence of gender dysphoria and transgender experience in the United States is likely approximately 0.3% to 0.5%1 highlight the importance of accessible and affordable transgender-specific care. Transgender individuals are known to be a population at risk for multiple mental health challenges, as well as negative and dangerous sequelae of maladaptive coping behaviors.2-4 Transgender women, particularly transgender women of color, are at even higher risk.5,6 In this issue, Reisner and colleagues7 affirm an extraordinarily high prevalence of mental health diagnoses, including lifetime episode of major depressive disorder (35.4%), generalized anxiety disorder (7.9%), suicidality (20.2%), posttraumatic stress disorder (9.8%), and substance dependence. These findings are certainly not new; increased prevalence of mental health morbidities has been reported consistently among transgender youth3,4,8,9 seeking care at gender-specific clinical sites. Disproportionately high levels of depression, anxiety, substance use, social isolation, self-harm, and suicidality are consistent findings in these reports. What is distinct about the study by Reisner et al7 is that it examines a cohort of young transgender women recruited from the community, rather than from a population of those with the resources to access transgender-specific health care. Not unexpectedly, more than three-quarters of these young women were unemployed, with nearly half reporting an annual income of less than $10 000. That prevalence rates of depression are notably higher in this community sample of transfeminine youth and young adults than in cohorts recruited from care sites underscores the potential influence of lack of access to services, both medical and mental health. Timely and appropriate care for transgender adolescents and young adults is imperative to help them achieve health and wellness. Scientists and health care professionals have tried to understand the nature of the relationship between transgender experience, gender dysphoria, and mental health morbidities for decades.10-12 Although the question of causality has largely been put to rest, there are clinicians, parents, and even community members who continue to posit that preexisting mental health morbidities and trauma lead to gender dysphoria. Routine timely and appropriate treatment for transgender youth may contribute to structural change and, ultimately, the waning of negative mental health sequelae and the behaviors that can put youth at risk for sexually transmitted infections, violence, substance abuse, and incarceration. Although care services for transgender youth have expanded around the country, the scientific and professional provider community still remains largely uncertain about the complex nature of transgender experience, especially in regard to youth. What is clear is that mental health services are lacking and are inaccessible to much of the transgender population no matter their age.13 This service gap is contributed to not only by the limited number of mental health professionals familiar with and experienced working with transgender youth but also by the lack of clarity about the role of mental health professionals in the care of gender nonconforming and transgender youth. Historically, mental health professionals have been charged with ensuring “readiness” for phenotypic transition, along with establishing a therapeutic relationship that will help young people navigate this very same transition. These 2 tasks are at odds with each other because establishing a therapeutic relationship entails honesty and a sense of safety that can be compromised if young people believe that what they need and deserve (potentially blockers, hormones, or surgery) can be denied them according to the information they provide to the therapist. We can reconfigure the current model of care with a new paradigm by acknowledging the critical importance of skilled and well-informed mental health professionals for successful and supported phenotypic gender transitions. As we move away from our historical practice of pathologizing transgender experience and identity, we can improve our understanding of gender dysphoria and the psychiatric morbidities that so often accompany it. Unfortunately, although professional organizations continue to use models of care for transgender patients that include elements of the gatekeeper practice, not only will therapeutic relationships between transgender individuals and their therapists potentially be compromised but also there will continue to be a seemingly insurmountable health disparity that arises because of the paucity of mental health professionals available to provide readiness assessments. The entire framework of transgender health care would benefit from a restructuring to meet the needs of patients and clients, as well as acknowledging pragmatic limitations of available professionals. Back to top Article Information Corresponding Author: Johanna Olson-Kennedy, MD, Children’s Hospital Los Angeles, 5000 Sunset Blvd, Fourth Floor, Los Angeles, CA 90027 (firstname.lastname@example.org). Published Online: March 21, 2016. doi:10.1001/jamapediatrics.2016.0155. Conflict of Interest Disclosures: None reported. References 1. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? http://williamsinstitute.law.ucla.edu/research/census-lgbt-demographics-studies/how-many-people-are-lesbian-gay-bisexual-and-transgender/. April 2011. 2. Corliss HL, Belzer M, Forbes C, Wilson EC. An evaluation of service utilization among male to female transgender youth: qualitative study of a clinic-based sample. J LGBT Health Res. 2007;3(2):49-61.PubMedGoogle ScholarCrossref 3. Reisner SL, Vetters R, Leclerc M, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. J Adolesc Health. 2015;56(3):274-279.PubMedGoogle ScholarCrossref 4. Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria. J Adolesc Health. 2015;57(4):374-380.PubMedGoogle ScholarCrossref 5. Wilson EC, Garofalo R, Harris RD, et al; Transgender Advisory Committee and the Adolescent Medicine Trials Network for HIV/AIDS Interventions. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav. 2009;13(5):902-913.PubMedGoogle ScholarCrossref 6. Garofalo R, Deleon J, Osmer E, Doll M, Harper GW. Overlooked, misunderstood and at-risk: exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health. 2006;38(3):230-236.PubMedGoogle ScholarCrossref 7. Reisner SL, Biello KB, White Hughto JM, et al. Psychiatric diagnoses and comorbidities in a diverse, multicity cohort of young transgender women: baseline findings from Project LifeSkills [published online March 21, 2016]. JAMA Pediatr. doi:10.1001/jamapediatrics.2016.0067.Google Scholar 8. Khatchadourian K, Amed S, Metzger DL. Clinical management of youth with gender dysphoria in Vancouver. J Pediatr. 2014;164(4):906-911.PubMedGoogle ScholarCrossref 9. Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics. 2012;129(3):418-425.PubMedGoogle ScholarCrossref 10. Tuber S, Coates S. Indices of psychopathology in the Rorschachs of boys with severe gender identity disorder: a comparison with normal control subjects. J Pers Assess. 1989;53(1):100-112.PubMedGoogle ScholarCrossref 11. Meyer JK. The theory of gender identity disorders. J Am Psychoanal Assoc. 1982;30(2):381-418.PubMedGoogle ScholarCrossref 12. Coates S. Ontogenesis of boyhood gender identity disorder. J Am Acad Psychoanal. 1990;18(3):414-438.PubMedGoogle Scholar 13. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
JAMA Pediatrics – American Medical Association
Published: May 1, 2016
Keywords: adolescent,adolescent psychiatry,comorbidity,diagnosis, dual (psychiatry),health services accessibility,mental disorders,mental health services,socioeconomic factors,gender identity disorder in adolescents or adults,gender dysphoria,gender identity disorder of childhood