Mental Health in Transgender

Mental health is another dimension of human health. Staying mentally healthy is not only about being free from psychiatric illness, but rather, the interaction between physical, mental and social factors together influences the individual’s overall well-being.

The contributor to mental health issues among transgender people is stigma. This includes structural stigma (i.e.: loss of work opportunities in some fields or access to certain services), interpersonal stigma (i.e.: bullying, physical abuse, and sexual abuse), and individual stigma (i.e.: feelings of insecurity, anxiety, and avoidance of situations with potential discrimination). All of these factors are critically important to the daily life and mental health quality in the transgender population.

Due to the different forms of stigma, there is a high prevalence of some mental health problems among the transgender population such as depression, anxiety, self-injury, and post-traumatic stress.

Depression

Depression is a mood disorder characterized by feelings of sadness and diminished interest in activities once enjoyed. Usually other symptoms are present, such as loss of appetite or overeating, insomnia or excessive sleep, fatigue, lack of energy, slow movement or restlessness, impaired concentration, and recurrent thoughts of death or self-injury. Several risk factors associated with depression are common in the transgender population such as unemployment, trauma, a lack of social support, family conflict and rejection, history of substance use, history of chronic medical conditions, and partner violence.

The prevalence of depression among transgender people is high, especially in the elderly, in those with low self-esteem, in those with interpersonal relationship issues, and in those with low social support. Gender-affirming hormone treatment can reduce the risk of depression.

Screening for depression can be carried out using questionnaires, such as Patient Health Questionnaire-9 (PHQ-9). PHQ-9 is suitable for depression screening at primary care facilities. The questionnaire, which has been already translated into Thai, is presented in Table 1 along with result calculation and interpretation.

Patient Health Questionnaire-9

For the past two weeks, how often have you had the following symptoms?	Not at all	Some days (1-7 days)	Quite often (> 7 days)	Nearly every day
1. Little interest or pleasure in doing activities?
2. Feeling down, depressed, or hopeless?
3. Troublefallingasleep,sleepingfitfully, or sleeping too much?
4. Feeling tired or having little energy?
5. Losing appetite or overeating?
6. Feeling bad about yourself – or think that you are a failure or that you let yourself or your family down?
7. Trouble concentrating on things, such as reading the newspaper or watching television?
8. Moving or speaking noticeably slower? Or so fidgety and restless that you have been moving a lot more than usual?
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

Result interpretation

The result is interpreted as follows: Not at all = 0 point, Some days = 1 point, Quite often = 2 points, and Nearly every day = 3 points. The points are added up. Please note that the cut-off score of the PHQ-9 could vary in different cultural contexts. We recommend that users interpret PHQ-9 scores according to validity and reliability studies specific to their language and culture. In the PHQ-9 Thai version, if the total score equals to 9 or more, the respondents may have major depression.

In case of severe and continued depression that impairs daily life and functioning, the individual is diagnosed with a major depressive disorder, according to the depression diagnosis criteria by the American Psychiatric Association as follows:

The individual must be experiencing at least five of the following symptoms during the same two-week period, which significantly affects some aspect of their daily life or function. At least one of the symptoms should be either (1) or (2).
1. Depressed mood most of the day, every day.
2. Loss of interest or pleasure in activities he/she once liked most of the day, nearly every day.
3. Weight loss or weight gain (at least five percent of weight within a month) or decrease or increase in appetite nearly every day.
4. Insomnia or excessive sleep nearly every day.
5. Restlessness or lethargy nearly every day.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
8. Diminished ability to concentrate, or indecisiveness, nearly every day.
9. Recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt or a specific plan to commit suicide.
The symptoms cause great distress or result in a significant impairment in social, occupational, or other important areas of functioning.
The symptoms do not result from other medical conditions or substance use.

Healthcare providers caring for transgender individuals suffering from depressive symptoms should take a history and physical examination to differentiate the condition from other disorders that can mimic depression such as bipolar disorder, depressive disorder due to another medical condition (i.e.: from hypothyroidism or stroke), substance/medication-induced depressive disorder, and adjustment disorder with depressed mood. They should consider referring the individuals to a psychiatrist to receive appropriate treatment.

The providers may also assess other potential psychiatric conditions or comorbidities, such as risks associated with suicide, substance use, anxiety, and other psychosocial issues that may result in depression, such as stigma and low social support. In addition, they should assess protective factors, such as interpersonal relationships.

Recommendations for healthcare providers with transgender patients suffering from depression

Have a strong fund of knowledge such as the ability to differentiate between gender identity, sexual orientation, and sexual expression. Display an appropriate attitude.
Assess common possible risk factors associated with depression such as stigma, substance use, low social support, and family issues.
Screen for depression through interviews and/or questionnaires i.e.: PHQ-9.
Conduct additional interviews to differentiate depression from other psychiatric or medical conditions, and/or evaluate for the presence of other concomitant psychiatric or medical comorbidities, and/or psychosocial issues.
Assess risks of suicide or self-injury.
Provide psychosocial treatment using guided self-help,12 counseling, or family counseling, for example.
Treat moderate or severe depression patients with medication, whereby selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine and sertraline are first line treatment choices. The common side effects of SSRIs include headaches or gastrointestinal disturbances. Care should be taken in administering these medicines in conjunction with other medications and hormone therapy.
Administer medication based on symptoms, for example, benzodiazepines for insomnia.
Consider referring severe cases, those at risk for suicide, those with other concomitant psychiatric comorbidities, those with complex medical conditions, or those with treatment-resistant depression to a psychiatrist.

Anxiety

Characterized by fear, anticipation, or thinking of potential dangers in the future. Anxiety is a common mood that can be found in the general population; however, if it is so severe that it affects daily life functioning or co-exists with other symptoms, for instance, insomnia, impaired concentration, irritability, or physical bodily pain, it may be classified as an anxiety disorder. This is a common psychiatric disorder among transgender people. Providers may screen for anxiety using tests such as the Generalized Anxiety Disorder 7-item (GAD-7) scale, taking a full history, and provide primary care based on recommendations for treatment of clinically significant anxiety using antidepressants. Other potential mental health issues among young transgender people include self-injury, substance use, eating disorders, and mental disorders.

Mental health impacts of gender-affirming hormone treatment

Taking gender-affirming hormones may affect mental health as follows:

Depression

The prevalence of depression among transgender people who receive gender-affirming hormone therapy is lower than among their counterparts who do not. However, some research suggested that in long-term follow-up, the level of depression does not change after gender-affirming hormone treatment. Nevertheless, treatment can increase the level of self-esteem.

Anxiety

Gender-affirming hormone treatment can reduce the level of anxiety in transgender people.

Personality-related Psychopathology

Feminizing hormone treatment can reduce personality-related psychopathology, which may affect the mental wellbeing among transgender women.

Quality of life related to mental health

Transgender men receiving masculinizing hormone treatment were found to have a better quality of life in emotional and social terms. Quality of life in psychosocial and mental health terms is increased for transgender men and transgender women who receive gender-affirming hormone treatment compared to their counterparts who do not.

Dissociative disorder

Dissociative disorder is a spectrum of mental illness which involves a disconnect between thoughts, perceptions, actions, and identity. Gender-affirming hormone treatment reduces symptoms of dissociation statistically and significantly.

Psychosocial Life, Interpersonal Relationships and Emotion

The emotional benefit of gender affirming hormone treatment is greater in transgender women than in transgender men. In addition, hormone treatment helps to reduce the issues with socialization and interpersonal relationships.

Distress

Can be composed of social distress (such as avoidance of social interactions), and perceived distress (for example, self-perceived impairment of social interactions). Transgender individuals who do not receive gender affirming hormone treatment were found to have a greater level of distress than those who do. Transgender women who receive gender affirming hormone treatment suffer less body uneasiness, which is associated with higher estradiol levels; however, such difference is not found in transgender men.

The effects of gender affirming hormone treatment on mental health vary according to type and blood hormone levels. Masculinizing hormones like testosterone increase sexual desire. The higher level of testosterone or a supraphysiologic blood level may result in exacerbation of mania or psychosis, such as in bipolar disorder and schizoaffective disorder. Hormones administered to transgender women, such as estrogen, or anti-androgen, reduce sexual desire.

Refer: Mental Health in Transgender Adults, The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University

REFERENCES

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