Gender-Affirming Mental Health, Best Practices

In this video, Meagan Thistle, associate digital editor, Psych Congress Network interviews Eric Yarbrough, MD, private practice, New York, New York, to expand on his Psych Congress 2021 session, "Transgender Mental Health." Dr Yarbrough discusses best practices for his colleagues surrounding gender dysphoria, prescribing hormone therapy for patients transitioning, as well as the benefits and impact of gender-affirming psychotherapy.

Read the transcript:

Meagan Thistle:  Welcome, everyone. We are sitting down at Psych Congress with Eric Yarbrough. If you'd like to introduce yourself.

Dr Eric Yarbrough:  Hi, I'm Eric Yarbrough. I'm a psychiatrist in New York. I work primarily with LGBTQ people.

Thistle:  Thank you for joining us. Let's jump in. Could you give us a little bit of information? What you think the key takeaways will be from your session, and how clinicians can take that back into their practice?

Dr Yarbrough:  I hope to provide a general overview for a psychiatrist that feels like they don't know what they're doing when working with a transgender person. It's just a starting point for people to go off of, so they feel comfortable working with anybody that identifies that way.

Thistle:  Giving those pearls and nuggets to take back.

Dr Yarbrough:  Exactly.

Thistle:  Awesome. If you could describe for us what gender dysphoria is, and what do clinicians need to know about the condition?

Dr Yarbrough:  Gender dysphoria is basically a diagnosis in the DSM. If I were to sum it up, it would be to say that it's someone who was assigned a certain sex at birth, male or female. Then, as they grew up, they discover that they don't feel that way inside. They might identify as the opposite gender.

Thistle:  I know there was a reclassification in the DSM-5. Do you want to elaborate on that?

Dr Yarbrough:  It's a lot of politics involved, but it used to be called gender identity disorder. The disorder part pathologized the population. We were trying to create a way in which people get access to care, and not necessarily pathologize gender diversity.

Thistle:  What are the key best practices surrounding prescribing hormones for transgender people?

Dr Yarbrough:  Hormones is one of the topics that usually makes people most uncomfortable because psychiatrists aren't that used to prescribing the medication. Hormones are just one way in which transgender people can get gender-affirming care, but a lot of people decide to go that route.

I think that psychiatrists, if they become comfortable with understanding what they do to the body and how long it takes over a period of time and then understanding the risks and benefits, then they will be more comfortable not only prescribing it, but working with people that are on the medication.

Thistle:  Do you have any resources you could recommend where clinicians could go to maybe find that comfort and find the terms and jargon that might make people are comfortable?

Dr. Yarbrough:  The primary resource is called WPATH. It's the World Professional Association of Transgender Health. It's a free resource online. If someone just googles WPATH, they'll come to their page. They offer a complete guide on how to work with transgender people free of charge.

Thistle:  Awesome. That's great. It's a free resource. How does gender-affirming psychotherapy benefit the patient? How can clinicians begin to bring that into their practice?

Dr Yarbrough:  Gender affirming psychotherapy. That's another phrase that I don't think people understand. It's basically approaching a patient from a place where you respect their gender identity, whatever it is. If someone comes in your office and identifies as female, regardless of what's on their driver's license or insurance card, that's how you refer to them.

You refer them to by the name that they choose to be called. It starts there, and not questioning their identity and who they are because probably people have been doing that their whole life. If you meet people where they're at, you're providing affirming care.

Thistle:  You mentioned that maybe not looking at what's on their insurance card. Is there anything in an intake form or anything that a clinician could do before someone steps into the office that might make things a little more comfortable?

Dr Yarbrough:  There are, I guess, sophisticated ways of in-taking people now where they ask people's gender identity that's on the form. They might ask their sex, male or female, but then they also ask what their gender identity and pronouns are. Sometimes clinicians can have that information going into the room.

However, if you walk into a room and someone identifies as transgender, I mentioned that, you introduce yourself, identify yourself with your own pronouns, "I'm Eric. I go by he/him. Can you tell me what you refer to yourself as?" That's a simple introduction.

Thistle:  Awesome. Doing the same and setting that precedent?

Dr. Yarbrough:  It normalizes the experience.

Thistle:  Great. Do you have any other final thoughts or anything else you want to share with the clinicians here and who will be watching this?

Dr Yarbrough:  I think the main problem with working with transgender people is they don't have access to care. A lot of psychiatrists are uncomfortable working with the population. If people educated themselves even on a minor level, then we'd have a lot more access for them.

They need treatment in things like depression and anxiety and schizophrenia, just like anybody else does. Their gender identity is not usually the main reason they go to see a psychiatrist.

Thistle:  Interesting. Sorry, I keep asking you follow-ups, but this is very interesting.

Dr Yarbrough: That's fine.

Thistle:  You're saying the access to care. What barriers are in place that you maybe clinicians can help work on? If you want to maybe elaborate on the barriers that they'd might experience?

Dr Yarbrough:  Some transgender people might call a psychiatrist and ask for an appointment. When they identify themselves as transgender, the psychiatrist says I don't work with that population.

They might go to a clinic and the front desk staff or whoever is meeting the person first might have a certain prejudice against transgender people and turn them away simply because of their attitude and how they treat the person. Transgender people can come across all kinds of different very negative attitudes, so it's very hard for them to get a compassionate care.

Thistle:  Got you. Understood. I guess a final question would be how can a clinician work with their team and staff to take away some of those preconceived notions? I know you mentioned some resources, but I know sometimes folks might not feel comfortable talking about these things. Do you have any thoughts on how they might be able to approach that?

Dr Yarbrough:  Most people, because of the number of transgender people in this world, know someone who's transgender, whether they know it or not. Everybody has a gender identity, so they identify as masculine or feminine or somewhere in between.

Getting people comfortable with that and understanding that they fall on that spectrum, too, that usually opens the door to them understanding where the transgender people might be coming from.

Setting a standard of care in an office environment wherever you work or an inpatient unit or a clinic, just saying, whatever your personal beliefs are, this is how we work with this population and this is what we expect.

Thistle:  Awesome. Thank you. I know people will get a lot from your session. I'm excited to share this with folks and thank you for joining us.

Dr Yarbrough:  Thank you for having me.

Thistle:  Thank you.

Eric Yarbrough, MD, has a private practice in New York, New York. He started his training by completing medical school at the University of Alabama School of Medicine and specialized in psychiatry at St. Luke's Roosevelt Hospital in New York City. For the first 3 years of his career, he worked at St. Luke's Hospital both as Associate Training Director and as a general outpatient psychiatrist for patients, including those living with serious mental illness.

His career has been focused on the LGBTQ population previously serving as President of AGLP: The Association of LGBTQ Psychiatrists, Director of Psychiatry at Callen-Lorde Community Health Center, one of the largest LGBTQ Medical Centers, and medical director of the Gay Men’s Health Crisis (GMHC). He is a Distinguished Fellow of the American Psychiatric Association and serves as their Chair on the Council of Minority Mental Health and Health Disparities.