About two years ago, one of the psychiatry residents put together a conference on LGBTQI issues with outside speakers, and we decided to expand on the idea. I had given a seminar on the standards of care for transgender patients last fall and we branched out from there. We wanted to learn about the standards of care in terms of transgender surgery, to discuss overall psychiatric standards of care in the LGBT community, and to hear from individuals in the community themselves.

It just grew exponentially. We reserved an auditorium at Friends with 100 seats, and interest was so high that we had to turn people away. The program was really well received, so we look forward to continuing it, to share the knowledge and the issues that are faced within the LGBT community and to learn how we can better serve the community from a mental health standpoint.

An introduction to transgender medicine and surgery was presented by Sherman Leis, DO, of the Philadelphia Center for Transgender Surgery, who is chair of the Division of Plastic & Reconstructive Surgery at Philadelphia College of Osteopathic Medicine. Leis has been performing sexual reassignment surgery for more than 30 years. He discussed the different procedures one can have and the appropriate age for surgery — a heavily debated topic.

To have sexual reassignment surgery in the United States at this time, the patient has to have reached the age of full consent, 18 (the age is 16 in some European countries). Hormone therapy can start at an earlier age. To have genital reconstruction, the patient has to have had two evaluations by mental health professionals. The World Professional Association for Transgender Health has put out guidelines, and that's pretty much what everyone follows (wpath.org).

Standards of transgender mental health care and best practices were presented by Sarah Noble, DO, from the Department of Psychiatry at Albert Einstein Medical Center. Noble went over terminology used within the LGBT community — things you should say, things you shouldn't say. She talked about what to be aware of when you have LGBT patients on the unit or when you are meeting a patient for the first time. Basically, it's a matter of opening your mind up and allowing them to help you as much as you are helping them. You have to be more culturally aware to treat that person with respect.

For example, when a transgender individual comes into the hospital, where should they be placed on the unit? In terms of policy, the consensus is they should be placed wherever they feel they should be. So you find out how they see themselves. You introduce yourself: My name is Francis Smith, I go by he, his and him pronouns. Then you ask the patient to introduce themselves. You will see how they view themselves and express themselves, and that will also show the patient that you are aware and open to helping them the best that you can. It's the easiest way to open that door and find out how they see themselves and how they want others to see them.

First-Person Perspective

Paula Neira, MSN, JD, RN, a nurse educator at Johns Hopkins, gave us a first-person perspective on what it is like to serve in the military as a man when you don't identify as a man. Paul Neira graduated from the Naval Academy in 1985. During his time in the Navy, he wanted to transition from male to female, and he decided he needed to exit the military, although the Navy was really his calling. This was even before the "Don't Ask, Don't Tell" policy was instituted.

Later, Neira helped lead the effort to defeat Don't Ask, Don't Tell (repealed in 2010), so that gay and lesbian individuals could serve. However, that policy had nothing to do with transgender people, so that was still an issue until June 30 of this year, when the Pentagon lifted the ban on military service by transgender Americans.

It was eye-opening to hear from someone who has gone through the fight, who has lived with and witnessed these gender-identity issues. It's very different from reading about it or hearing about it from a faculty member.

Resources in the City

The director of LGBT Affairs in the Office of the Mayor, Nellie Fitzpatrick, was part of a panel of experts who discussed LGBT Health Care, Public Health and Public Policy. Fitzpatrick was instrumental in creating Google apps to find out where transgender bathrooms are in the city.

Among other topics from the news, the panel discussed transgender individuals being able to use the bathroom of their choice. That's not a problem in Philadelphia, and won't be, officials assured us, but in other parts of the country it's an issue. Fitzpatrick also mentioned a new rule, issued under the nondiscrimination protections of the Affordable Care Act, that transgender people cannot be denied health care by professionals that receive federal funding, and that it is discriminatory to refuse them access to transitionrelated services. All insurance companies have to be compliant this year.

Another panelist was Deja Lynn Alvarez, program director of the Divine Light LGBTQ Wellness Center, a shelter for LGBTQ individuals who are homeless. People in transition or questioning, especially young people, who are going through this at a very turbulent time in life, often find their families aren't on board or even open to the idea. Sometimes they become homeless, so knowing that there are places where they can go to be safe and have in-house shelter is very important.

By the same token, if a psychiatry resident is called for a consult in the hospital and the patient is a transgender or questioning youth, just giving them a safe place to talk is helpful. It's vital to have as complete a picture as possible in order to figure out how best to help them. Providing that empathetic environment and acceptance, the space to open up and allow them to share what's going on with their life, is the best thing you can do to help the patient. Showing that you respect them and want to help them can, in and of itself, be very therapeutic. Sometimes you might be the first person who has ever given them the chance to express themselves. So having that start from the door is very important.

One of the things I find interesting is that gender identity disorder was introduced into the Diagnostic and Statistical Manual of Mental Disorders more than 30 years ago (the term was changed to "gender dysphoria" in the DSM-5 in 2013), yet the American Psychiatric Association has never taken a stance on specific treatment guidelines. A couple of years ago, the APA put together a task force to see if there was enough evidence-based medicine within the databases and literature to support formal guidelines, and the consensus was yes, the association should move forward.

Among the task force recommendations was that mental health and medical professionals have symposiums together and invite experts to educate them on the issues and current standards, while guidelines are being developed. So to have a day, as we did, where we can get together, learn about and discuss the issues, and talk about creating what is essentially a standard of care, was both enlightening and important.

— Francis Smith, DO
Psychiatry Resident