Most transgender individuals will find themselves interacting with the mental healthcare system at some point in their lives. However, many psychiatric hospitals and general healthcare facilities do not have clear written policies to address the unique needs of transgender patients. This is extremely problematic because it can lead to discriminatory practices, inadequate care, trauma, and/or aversion to seeking needed healthcare services in the future.

The most common DSM-V diagnosis given to transgender individuals is gender dysphoria. The criteria for this diagnosis is:

In adolescents and adults gender dysphoria diagnosis involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics
3. A strong desire for the primary and/or secondary sex characteristics of the other gender
4. A strong desire to be of the other gender
5. A strong desire to be treated as the other gender
6. A strong conviction that one has the typical feelings and reactions of the other gender

However, it is possible for transgender individuals to have a concurrent psychiatric diagnosis, and in fact, it is quite common. Many transgender individuals to experience anxiety, depression, and substance abuse. This may have a large connection to societal attitudes towards gender and discrimination transgender individuals often face. Transgender individuals face discrimination in employment, housing, and healthcare. Many transgender individuals contemplate suicide and 41 percent of transgender individuals make a suicide attempt. Therefore, it is highly likely that a transgender person will become a patient in a psychiatric hospital in his or her lifetime.  It is critical that psychiatric hospitals, both public and private, have clear policies to guarantee that transgender patients are treated with dignity, respect, and appropriate care. However, most psychiatric hospitals do not have written policies to address transgender patients.

How can psychiatric hospitals protect transgender patients?

Congress passed the Prison Rape Elimination Act (PREA) in 2003 and published standards in June 2009 that outline how transgender individuals within the justice system should be treated to safeguard from sexual violence, both from becoming a victim or perpetrator.  Psychiatric hospitals are very similar to prisons; individuals are denied free access to the outside, often are segregated based upon gender, and must conform to authority. Therefore, the standards issued in the PREA are a great place to start when creating a written policy to addressing the needs of transgender psychiatric patients.

The specific parts of the policy that psychiatric hospitals should focus upon are screening and classification, and housing. The PREA states: Facilities must screen all individuals at admission and upon transfer to assess their risk of experiencing or perpetrating abuse, including identifying those who may be at risk because of their transgender status, gender nonconformity, sexual orientation, or intersex condition. The individual’s own perception of their vulnerability must also be considered.

Individuals may not be disciplined for any refusal or nondisclosure during screening regarding gender identity, sexual orientation, intersex condition, disability status, or prior sexual victimization.

Facilities must use this information to make appropriate, individualized decisions about an individual’s security classification and housing placement.

Housing transgender people

Decisions about where a transgender person, or a person with an intersex condition, is housed must be made on a case-by-case basis; they cannot be made solely on the basis of a person’s anatomy or gender assigned at birth. This means that, for example, every transgender woman must be assessed individually to determine whether she would be best housed with other women instead of in a men’s facility. An individual’s views regarding their personal safety must be seriously considered.

These decisions must be reassessed at least twice per year to consider changed circumstances such as incidents of abuse or changes in an individual’s appearance or medical treatment.

All transgender people and people with intersex conditions must be given the opportunity to shower separately from other inmates if they wish, regardless of where they are housed.

Hospitals may access resources from the National Institute of Corrections to create a written policy for their specific patient population. https://static.nicic.gov/Library/026702.pdf

It is critical that mental health practitioners and healthcare facilities create an environment of acceptance, compassion, dignity, and respect to ensure that transgender individuals receive the care they need. Creating a written policy will assist in this mission and hopefully foster an atmosphere of trust between the transgender community and the healthcare community.