June 9, 2021

[Edited for grammar and clarity]

What all physicians need to know about transgender-inclusive care

[musical intro]

David Gratzer: Welcome to Quick Takes. My name is Dr. David Gratzer, I'm a psychiatrist here at the Center for Addiction and Mental Health. Today, we're in Pride Month, and we thought it appropriate to talk about transgender-inclusive care. We'll talk today about what's in the literature. We'll talk today about clinical implications. And we'll talk today with two experts. Joining us, Dr. June Lam, a psychiatrist here at the Center for Addiction and Mental Health, who is also a Ph.D. student whose work, including with Dr. Abramovich, our other guest, focuses on access and access issues for transgender post-discharge mental health care. Also joining us is Dr. Alex Abramovich, who's an independent scientist here at the Center for Addiction and Mental Health and an assistant professor at the University of Toronto. His research focuses on addressing public health needs of sexual and gender minority populations. Welcome to both of you.

June Lam and Alex Abramovich: Thank you so much for having us.

David Gratzer: And let's start by clarifying what pronouns you go by. Dr. Lam?

June Lam: I use he/him pronouns.

David Gratzer: Dr. Abramovich?

Alex Abramovich: I go by he and him pronouns.

David Gratzer: And note the choice of language informed by Dr. Lam's email earlier today. So we no longer talk about preferred pronouns. I assume then the better expression is "pronouns you go by". Fair?

June Lam: Yes.

David Gratzer: Language is important.

Alex Abramovich: Yes, I think I agree with you. I think language is incredibly important and I very much appreciate that you asked, first of all, that you ask what pronouns we go by. I think that's an incredibly important question. And I'm happy to see that being more commonly asked these days. And exactly as June had mentioned – it's not really about preference. When you ask someone “what are your preferred pronouns?”, it sounds like you have a preference. Your preference might be he or she, but it's not a preference. Most of us. It's not a preference. It's what we go by. I go by he and him. I don't prefer to go by he and him. That is what I go by. You know, there's never a time that I prefer she or her. So that that's why language is so important when we ask about pronouns.

David Gratzer: Fair enough. And then speaking about language, why don't we also talk a bit about definitions? Dr. Lam.

June Lam: Yes, so I was thinking about this, and language changes in this work quickly, and I think it can be overwhelming sometimes. I think it's OK. I think one of the important things, maybe critically, is that if you do make a mistake or if you do say something wrong – we all do that and it's OK – and that we should just learn and then not make the same mistake next time. So, in terms of definitions, first, transgender. Transgender people are people whose gender identity is different than the sex they were assigned at birth. There are also non-binary people. Non-binary people are people whose gender is not part of the rigid gender binary. So, they may not identify as a man or a woman. They identify outside of that binary within a spectrum. And so that's also another term that is important to define. Cisgender refers to people whose gender identity is consistent with the sex they were assigned at birth. There are so many concepts. Dr Abramovich, do you have other important definitions you want to add?

Alex Abramovich: No, but I do what I would like to say that I think it's very important that we use these terms so we can say transgender or trans. We can say cisgender, cis. I don't think it's appropriate to say trans and non-trans. I think that we should use the terms that we have: transgender and cisgender. And the reason for that is if we don't name it, then we're always “othering” trans people and trans people are always seen as the other. But when we use this language, we actually create much more room for acceptance, and we create more room for different ways of being. So that's why I think it's important that we use these terms.

David Gratzer: Excellent. We're talking today about transgender care, transgender-inclusive care, rather. Why is this important?

Alex Abramovich: So, this is important because research has consistently shown that trans individuals are medically underserved and experience poor mental health outcomes and high rates of disease burden – compared to cisgender individuals. So, for example, we know that trans individuals experience significantly higher rates of suicidality, substance use, depression and anxiety. And this isn't because, you know, because a person identifies as trans. It's not because of their identity. But it rather has to do with social stigma, with identity-based rejection. There are so many factors that lead to these higher rates of mental health conditions.

David Gratzer: Dr. Lam?

June Lam: Yeah, I echo all of that. Trans people are at least zero-point-five percent of the population, but actually more recent study suggests that actually trans people are a greater prevalence than just zero-point-five percent of the population. And in our practice, all of us as clinicians will see trans people in our practice. And so it's important to be knowledgeable, to practice inclusive and safer care so that people feel like they can build a trusting alliance with us so that we can provide optimal care for them.

David Gratzer: And of course, Dr. Lam, you do practice as a psychiatrist. What are some tips you might have in terms of taking care of a patient who identifies as transgender?

June Lam: I think some of the tips that I have include introducing your own pronouns. I try to, with everyone, start by saying “my name is June Lam or Dr. Lam. I'm a psychiatrist. I use he/him pronouns.” Just to signal that you can't assume, you know, someone's pronouns or gender just by looking at someone and to normalize that it's OK to have conversations around pronouns and clarifying around that. I also try to ask people about their pronouns. I think it's important to validate experiences of oppression and transphobia that people experience. I was thinking about this, and I think one main tip that I would suggest for clinicians is: if someone presents either in the acute setting or as an outpatient with depression, anxiety, and they happen to be trans, I think it's important to ask what they think contributes to their mental health symptoms and to validate those experiences. As Dr. Abramovich alluded to, often, for trans people, the depression, anxiety or other mental health symptoms comes from not their identity, but from the oppression they experience. And if we don't ask about the social determinants of health or the oppression that they experience, we can't then tailor our treatment plans appropriately to addressing those concerns.

David Gratzer: Let me just follow up with that quickly. What's the way of phrasing that in terms of oppression or stigma that people might have faced over time? What advice might you give our clinician colleagues?

June Lam: I think I would maybe suggest you ask a version of: “You're coming in because of your mental health, and I would love to support you in that. What has contributed to your depressive symptoms or your anxiety symptoms? I know that sometimes for many trans people, it's their experiences. It's related to their experiences of transphobia, discrimination or rejection in the community. Does that resonate with your experience in any way?” I think it's important to have that knowledge, to ask openly, but also not to assume. For many, many people that may not be the case. It may not be related to discrimination or transphobia, but to make space to ask those questions,

David Gratzer: Direct, make space, listen. Dr. Abramovich, you, of course, approach this through the prism of research. What advice through that prism might you give our clinician colleagues?

Alex Abramovich: So, I think a lot of this really comes down to actually basic human respect and treating people in ways that you yourself are going to be treated. It sounds so easy because it actually is. I think that a lot of people actually complicate these issues, but they’re actually really not that complicated. You know, everybody gets to decide what their gender is, what pronoun they would like to be used when referring to them. And our name is such a fundamental part of our identity that I think it's safe to say that most of us expect to be called by our name or the name that we introduce ourselves with. And I'm sure that everyone listening can imagine what it would feel like to constantly be referred to by the wrong name and the wrong pronoun. Unfortunately, I would say most, if not all trans people know what that feels like. We know what it feels like to be erased and made invisible in very obvious and subtle ways by family, by friends, by organizations that refuse to recognize who we are. You know, there was a recent study that reported better mental health, including lower risk of depression and suicide among trans people who are addressed by their chosen name at school, work and at home. I also want to say that I think it's very important to know the difference between a question that is relevant to your clinical assessment versus a question that is, you know, that might be intrusive and only serves to satisfy your curiosity. And lastly, I do want to point out that I think it's very important to not out a trans person, meaning to not disclose a trans person's identity without asking them first. It's only up to the person to actually out themselves and disclose their own identity.

David Gratzer: Those are reasonable suggestions. And you talk about the literature. The two of you penned a paper for the Canadian Medical Association Journal a couple of years ago. And you talked about a few different things, but let's focus on the mental health implications. You talked about, in fact, a U.S. study suggesting 41 percent of transgender participants reported attempting suicide compared to only one point six percent of the general population.

What are your thoughts, Dr. Lam?

June Lam: Yes, thank you for that important question. That study is echoed by the Trans PULSE study, which is a Canadian survey of 433 trans Ontarians that found that forty three percent of trans Ontarians in that survey attempted suicide in their lifetime – which is much higher than the four percent lifetime prevalence of suicide attempts in the general Canadian population. I think the important thing, besides asking a trans person about suicidality, more importantly is asking where does that suicidality come from in terms of if you're feeling suicidal, what is contributing to that? And for some, or for many, it could be, again, related to social determinants of health, experiences of depression, discrimination. And so, if that's the case, we need to address that. And for some people, it's because they want to access medical transition, for example, such as gender affirming hormone therapy or transition related surgery. But the wait lists are long and it's very difficult to access. And so if that's the case, and that's one of the drivers of suicidality, then it's really important for us to then help someone navigate access to those medical transition tools.

One tip that I wanted to suggest and add for clinicians to think about is for trans people who want to change their gender marker and their legal name on their government issued ID. Sometimes they may require a physician or clinician letter of support. And so I would just say if someone asked you for a letter, please do it, because it could be lifesaving. It's easy to do. And it's just affirming, if nothing else, for someone's gender.

David Gratzer: So, one thing we might do for such a patient is advocate for access and referrals to appropriate clinics, as well as some education around opportunities and services available. What are other ways we can advocate for such patients? Dr. Abramovich.

Alex Abramovich: A lot of my work involves working with young trans individuals, LGBTQ2S youth, who are experiencing homelessness. And oftentimes they're experiencing homelessness because of due to family rejection and they can't stay at home. They don't really have anywhere safe to live, actually to sleep. And oftentimes they're experiencing significant barriers, just trying to access support, trying to access a safe place to sleep. And so something that I often suggest is that we need a more standardized model of care, whether that be in housing programs, whether that be in medical institutions. People need to know what to expect when they access the service. And unfortunately, currently that's not the case. Oftentimes, trans individuals talk about that if they access a service, it really depends on who is working on which given day. So, whether that be, you know, they might be able to connect with a clinician who they know is actually a little bit more trans-inclusive and they feel safe disclosing their identity. But then you go on another day and then you're not actually sure how a person is going to respond to you. So, I think it's very important that as clinicians, as services, that we work towards a more standardized model of care, and that involves ensuring that our institutional forms, our surveys include inclusive questions that ask about gender identity. When I say inclusive questions, I mean, if you're going to ask about gender, don't just say male female and add a checkbox that says other because a checkboxes that say “other” is literally othering people. And also, it actually doesn't provide us with any information about that person's identity. So ensuring that we actually have response options that truly reflect the ways that people identify so they don't have to categorize themselves in boxes that don't align with the way that they actually identify.

David Gratzer: I think you both agree that there has been progress. I think you both agree that there's a lot of work to be done. What's to be done? Dr. Lam.

June Lam: I think that's such a good question. There are so many things on my wish list – I wrote a little bit of a wish list. One thing I would say is I still think there's a lot to be done in terms of education. I'm really thankful for this podcast, in part because it hopefully will contribute to education. I still see a lot of medical notes where clinicians, including physicians, mis-gender people, patients, in the notes, even though there's a note from me or from another clinician that has clarified that person's gender identity and that person's pronouns. And we still mis-gender them in their notes. And I think that could be quite harmful and perpetuate some of the issues that we've talked about. So I would hope for more education so that, you know, trans care is not just is not considered specialized care. It's not just done by people at the CAMH Gender Identity Clinic where I work with my amazing colleagues. But trans care's just equitable, inclusive care for everybody walking into our front door. And that has to explicitly include trans people. And I have more wish list items, but I would stop there for now.

David Gratzer: Dr. Abramovich?

Alex Abramovich: I also think this is an incredibly important question and something that I think about often. I already spoke about the standardized model of delivery of care. So that's one thing, of course. And then I fully agree with June’s suggestions. And I have many suggestions. But one thing that I think about often, because I do quite a bit of work with all levels of government with regards to development of inclusive data collection tools, so what I would say is that all levels of government need to prioritize LGBTQ2S populations. And when I say this, I'm thinking about health care delivery. I'm thinking about there are strategies, homelessness strategies, their plans to end homelessness. Because we cannot end homelessness, for example, unless plans to end homelessness prioritize disproportionately represented populations such as LGBTQ2S individuals. And I truly believe that by making a commitment to actually prioritize LGBTQ2S populations, that we can create inclusive environments in medical services and housing programs where people can bring their full, authentic selves when they access services, and they may even learn to celebrate who they are.

David Gratzer: We've talked about the literature, we've talked about the interview, but thinking practically from a clinical perspective, some of these individuals will be on antidepressants, but of course, they might be getting surgeries or having hormone replacement therapies. Should we be concerned about drug interactions, Dr. Lam?

June Lam: That's a good question. In my experience, that is rarely a concern in terms of someone being on masculinization or feminizing hormone therapy and also being on psychiatric medications. One question that sometimes comes up is about prolactin elevation. So as you know, as many clinicians know, some of our antipsychotic medication, for example, can increase prolactin levels and estrogen can also increase prolactin levels. And so that's something just to be aware of. Family doctors or endocrinologists who end up prescribing hormone therapy are usually aware of that. So just to monitor prolactin levels and there are guidelines that exist, such as the Sherbourne Health and Rainbow Health Ontario has an amazing guideline that's freely available online in terms of how to prescribe a feminizing and masculinizing hormone therapy. And they talk about these issues, including prolactin elevation. And so just to be aware of it, not to be too concerned, just to monitor it. But that's really the main interaction that people are usually concerned about.

David Gratzer: This has been very helpful and informative. It is a Quick Takes tradition that we close with a rapid-fire minute. Since there are two of you, let's put two minutes on the clock. Let us begin.

Dr. Lam, biggest tip for clinical work?

June Lam: Validate people's experiences of oppression and transphobia when they tell you that it exists.

David Gratzer: Dr. Abramovich, are you hopeful for the future?

Alex Abramovich: I am hopeful for the future. Yes, it took me a second, but I am just thinking about the way that things have progressed, thinking back to when I first started doing this work. You know, sometimes things are very slow moving, very slowly, but we are definitely in a much better place than we were, let's say, 10 years ago.

David Gratzer: Dr. Lam, you see his unfettered enthusiasm and agree?

June Lam: Absolutely!

David Gratzer: What makes you feel hopeful, Dr. Abramovich?

Alex Abramovich: The young people who I work with actually fill me with an incredible amount of hope. I'm very, very passionate about the work that I do, and I feel extremely grateful to be able to work with such incredible young people.

David Gratzer: Dr. Lam, thinking of the clinicians listening today. One thing you would like them to do differently, perhaps?

June Lam: I would say please try not to assume that you know someone's name or pronouns or gender by just looking at somebody. Please, please ask and then please adjust your notes accordingly.

David Gratzer: Dr. Abramovich, you've contributed to the literature, and you read the literature. What's a paper that you thought was particularly meaningful?

Alex Abramovich: So, the Trans PULSE study actually that that has been very meaningful and has really informed a lot of the work that I do. And I'm happy to see that they recently conducted a Canada-wide Trans PULSE version. It's just really incredible to see when trans people are at the center of research and when trans voices are included and conducted in a really sort of community based, action-oriented manner.

David Gratzer: Dr. Lam, at the buzzer, one last question. What's one thing you would like clinicians to worry less about when talking with people?

June Lam: I would love clinicians to worry less about making mistakes. I think the problem is not making mistakes, I think we all make mistakes. I make mistakes all the time. This work can feel like it's full of minefields sometimes. It's full of mines sometimes. But I think the important thing is to try to learn, and if you make mistakes, to apologize, to not make a big deal out of it, to apologize, to move forward, but then try to learn so that you don't make that same mistake again.

David Gratzer: And that's this episode of Quick Takes. Thanks very much for joining us and a big thank you to our guests today, Drs. Lam and Abramovich. And, again, on the website, we've got more information, including links to some papers and resources that might prove useful in your clinical work.

Alex Abramovich: Thanks so much for having us.

June Lam: Thank you.

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Until next time.