Mental Health Diagnoses Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Study

Abstract

We performed a cross-sectional analysis of the prevalence of psychiatric diagnoses among transgender patients in clinical care using an all-payer electronic health record database. Of 10,270 transgender patients identified, 58% (n = 5940) had at least one psychiatric diagnosis compared with 13.6% (n = 7,311,780) in the control patient population (p < 0.0005). Transgender patients had a statistically significant increase in prevalence for all psychiatric diagnoses queried, with major depressive disorder and generalized anxiety disorder being the most common diagnoses (31% and 12%, respectively). Utilizing an all-payer database, although not without limitations, enables assessment of mental health and substance use diagnoses in this otherwise small population.

Characteristics of Transgender Individuals With Emergency Department Visits and Hospitalizations for Mental Health

“…The diagnostic patterns in the transgender samples are consistent with the two-to fivefold higher prevalence of depression among transgender individuals than in the general population (3-5, 14, 15). Although transgender individuals also have increased rates of anxiety-and trauma-related disorder diagnoses (3,14,15,20), this pattern was not reflected in our results. The multifold increase in personality disorder diagnoses we found in the transgender samples in this study may be partially explained by the minority stress model (11,21).…”

One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria

“…Such encounters can be experienced by patients as an attempt to withhold the treatment they so desperately want (Chiland, 1997). Further, patients with psychiatric diagnoses, highly prevalent in transgender-identifying populations (Gijs, van der Putten-Bierman, & De Cuypere, 2013;Goodman & Nash, 2018;Wanta, Niforatos, Durbak, Viguera, & Altinay, 2019), can potentially experience or misinterpret neutral (James et al, 2016). Weighted data b CDC BRFSS Survey, 2014-2017 (Baker, 2019).…”

“…In fact, failure to control for the subjects' baseline mental health makes it impossible to determine whether the mental health or the suicidality of subjects worsened, stayed the same, or potentially even improved after the non-affirming encounter. Given the high rate of co-occurring mental illness in transgender-identifying patients (Gijs et al, 2013;Goodman & Nash, 2018;Wanta et al, 2019), failure to control for prior mental health status is a serious methodological flaw. Turban et al's (2020) finding that mental health outcomes of persons exposed to GICE are worse than those whose encounters were "gender-affirming" is weakened by internal inconsistencies in the mental health outcome measures.…”

“…Such encounters can be experienced by patients as an attempt to withhold the treatment they so desperately want (Chiland, 1997 ). Further, patients with psychiatric diagnoses, highly prevalent in transgender-identifying populations (Gijs, van der Putten-Bierman, & De Cuypere, 2013 ; Goodman & Nash, 2018 ; Wanta, Niforatos, Durbak, Viguera, & Altinay, 2019 ), can potentially experience or misinterpret neutral interpersonal interactions as invalidating or rejecting (Barnow et al, 2009 ; Beck & Bredemeier, 2016 ; Gotlib, 1983 ). Not only does the survey question provide no detail to help discriminate between these essential therapy encounters and unethical conversion therapy, but it arguably biases the recall of neutral encounters toward recall of conversion by using emotionally charged language (e.g., “stop you being trans”) and by conflating recall of religiously motivated encounters with clinical ones.…”

“…In fact, failure to control for the subjects’ baseline mental health makes it impossible to determine whether the mental health or the suicidality of subjects worsened, stayed the same, or potentially even improved after the non-affirming encounter. Given the high rate of co-occurring mental illness in transgender-identifying patients (Gijs et al, 2013 ; Goodman & Nash, 2018 ; Wanta et al, 2019 ), failure to control for prior mental health status is a serious methodological flaw.…”