An Assessment of the Mental Health History of Patients in a Transgender Clinic in Kingston, Ontario

Introduction

Transgender individuals constitute a marginalized population that bears a disproportionate burden of mental illness. Through the Trans PULSE Project surveying transgender Ontarians, Bauer et al.¹ found 77% surveyed had ever considered suicide and 43% had ever attempted; Rotondi et al.² found the prevalence of active depressive symptoms to be over 60% of those surveyed. In contrast, Statistics Canada reported a 12-month prevalence of depression in the general population to be 4.7%.³ This discrepancy highlights the psychiatric needs, in addition to general medical needs, of the transgender population.

Recognizing unmet medical needs from the transgender population in the region, the Transgender Clinic at Kingston Health Sciences Centre (KTC) was established in June 2017 by Dr. Ashley Waddington, with services provided being primarily cross-hormone therapy and referrals for gender-affirming surgeries. Previously, the nearest access to trans-specific care was Ottawa (200 km from Kingston) or Toronto (260 km from Kingston). We have summarized here the mental health history of KTC patients to evaluate needs in our expanding clinic and provide data for others intending to set up transgender clinics of their own.

Method

A retrospective chart review of 108 patients referred to KTC prior to May 7, 2019, was performed with approval from Queen’s University and Affiliated Teaching Hospitals Health Sciences Research Ethics Board. Documentation included active psychiatric issues on first appointment, all diagnosed psychiatric conditions, current psychotropic medications, and current involvement of mental health services. Psychiatric conditions were grouped into clusters such as mood, anxiety, and neurodevelopmental. Psychotropic medications were grouped under their classifications, such as anti-depressant or stimulants.

Patients were classified as male-to-female (MtF), female-to-male (FtM), non-binary, or other per self-identification. Statistical analyses were performed with chi-square tests to assess differences in psychiatric diagnoses/treatment between MtF and FtM patients or Fisher’s exact test for those where cell counts were ≤5. A P < 0.05 denoted statistical significance. When cell counts were ≤5, the authors decided to suppress and present data as “≤5” to protect patient confidentiality.

Results

As of May 7, 2019, 108 patients had been referred to the KTC; 92 had been seen and 15 had first appointments pending. The 92 who had been seen included 26 MtF, 54 FtM, and 12 who identified as nonbinary or other. We saw a predominance of youths: 63 (68%) were 25 years or younger and the median age was 21 (interquartile range 16 to 29) years.

Among the 92 patients seen in the KTC, there was an 80.4% prevalence of ongoing psychiatric diagnosis and 87.0% lifetime prevalence (Table 1). Anxiety disorders were most common (62.0% lifetime diagnosis), followed by mood disorders (54.3%) and gender dysphoria (42.4%). Of the 72 patients with an active psychiatric condition, 40 were on at least 1 psychotropic medication and 58 were seeing a mental health professional. Of the 18 who had no active psychiatric issues, 8 were seeing a mental health professional. Only 22.8% had a documented history of suicide attempts or self-harm behaviors.

Table 1.

Summary of Psychiatric History and Treatment of Patients Presenting to the Transgender Clinic at Kingston Health Sciences Centre (KTC).

	Total (N = 92)
Psych history
Gender dysphoria or gender identity disorder	39 (42.4%)
Mood disorders	50 (54.3%)
Anxiety disorders	57 (62.0%)
Psychotic disorders	≤5
Post-traumatic stress disorder	13 (14.1%)
Personality disorder	11 (12.0%)
Neurodevelopmental disorder	19 (20.7%)
Adjustment disorder or situational crisis	≤5
History of suicide attempts, suicidal ideation or self-harm behaviors	21 (22.8%)
Eating disorder	≤5
Substance use disorder	16 (17.4%)
None	12 (13.0%)
Active psych issues
Gender dysphoria or gender identity disorder	34 (37.0%)
Mood disorders	35 (38.0%)
Anxiety disorders	54 (58.7%)
Psychotic disorders	≤5
Post-traumatic stress disorder	7 (7.6%)
Personality disorder	10 (10.9%)
Neurodevelopmental disorder	13 (14.1%)
Adjustment disorder or situational crisis	0 (0.0)
History of suicide attempts, suicidal ideation or self-harm behaviors	10 (10.9%)
Eating disorder	≤5
Substance use disorder	12 (13.0%)
None	18 (19.6%)
Psych meds at initial visit
SSRI/SNRI/NDRI/TCA/SARI	32 (36.8%)
Mood stabilizer	≤5
Benzodiazepine	6 (6.9%)
Antipsychotic	14 (16.1%)
Stimulant	7 (8.0%)
Gabapentinoid	≤5
Cannabinoid	≤5
Other	≤5
None	45 (51.7%)
Unknown	≤5
Seeing a mental health therapist
Psychiatrist	22 (23.9%)
Psychologist	16 (17.4%)
Social worker	20 (21.7%)
Counsellor/therapist	29 (31.5%)
School counsellor	≤5
Assertive Community Treatment (ACT) team	≤5
Group therapy	≤5
Other	≤5
None	26 (28.3%)

Note. Data were collected from retrospective chart review, including diagnoses included with referral to KTC and self-report of previously diagnosed conditions on presentation. Psychiatric conditions were grouped into the following categories: gender dysphoria or gender identity disorder, mood disorders (including unipolar depression, bipolar disorder), anxiety disorders (including generalized anxiety, social anxiety, obsessive-compulsive, and panic disorders), psychotic disorders (including schizophrenia, schizoaffective disorder, and delusional disorder), post-traumatic stress disorder, adjustment disorder, suicidal behavior/ideation and self-harm behaviors, eating disorders (including anorexia nervosa and bulimia), substance use disorders (including alcohol use, marijuana use, and opiate use disorders). Data with n ≤ 5 were suppressed for patient confidentiality.

There were no significant differences in the psychiatric conditions or treatment documented between individuals who were MtF and FtM.

Discussion

The rates of psychiatric illness in our transgender population by far exceeded 2012 data from Statistics Canada, which showed the general population had a 12-month prevalence of <3.0% for generalized anxiety and 4.7% for depression.³ However, Statistics Canada data do not necessarily serve as an accurate comparison due to differing data collection methods. Compared to Trans PULSE data for lifetime suicidal ideation of 77%¹ and active depressive symptomatology of 60%,² our documented combined rate of suicidal ideation, past attempts, and self-harm behavior was far lower at 23% and active mood disorder rate of 54%. These lower rates of psychiatric conditions may reflect incomplete documentation upon referral and intake for medical transition or positive changes toward acceptance of transgender individuals in the last decade.

In a transgender youth population, Reisner et al.⁴ found a prevalence of 50.6% for depression and 31.1% for anxiety, both meeting Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria. While rates of depression are comparable to ours, anxiety disorders affected 62% of our population; this may reflect less stringent methods of diagnosis by self-report and family physician, and age differences between the populations. Consistent with previous studies,⁴ no significant differences were found between psychiatric diagnoses of FtM versus MtF patients. This may indicate a common cause, transphobia, for elevated risk of mental illness regardless of assigned sex at birth.

Only 42.4% of our population had a diagnosis of gender dysphoria on presentation. Although certainly many transgender individuals do not experience clinical levels of distress over their gender incongruence, the low rate in our sample is also likely attributable to incomplete past medical records and that formal diagnosis was not required for referral to our clinic. However, this discrepancy furthers the debate that labeling all transgender people with a psychiatric diagnosis (gender dysphoria) is incongruent with a modern understanding of gender.⁵ Another assessment model, for example, meeting certain criteria rather than qualifying for a DSM diagnosis, may be more appropriate to determine access to transition-related care.

Eight patients with no mental health history were seeing a psychologist. Until 2016, transgender patients required an assessment through the Centre for Addiction and Mental Health to access gender-affirming surgeries. However, the assumption that all transgender individuals require mental health care may persist; referral patterns of transgender patients to psychology after 2016 should be assessed.

Our review reveals significant burden of mental illness in our transgender patients. We propose that clinics supporting transgender patients should ideally have a multidisciplinary team to fully support patients. Specifically, a trans-competent psychiatrist and/or psychologist would help integrate mental health with medical care. Improved access to mental health care in transgender populations is an important component of health equity, and involvement of mental health professionals in trans-specific clinics is one way this can be supported.