Gender-Affirming Psychiatry

I love practicing psychiatry.

It’s a fascinating and humbling puzzle to solve: humans are endlessly complex, and psychotropic medications—these little molecules available to us to treat everything from mild anxiety to severe psychosis—are blunt, imperfect, and sometimes life-changing. I’ll never be bored by the challenge it poses every day.

But an even more important challenge it presents involves the endless potential for human error and bias. Our internalized biases and fundamental human flaws can make us extensions of an oppressive culture, causing harm to patients.

I think it’s important we talk about what that looks like with trans and gender diverse communities, and how we can work to fix it.

Psychiatry has a storied history of upholding harmful cultural constructs, and even creating some of them.

It doesn’t take too deep a look into the annals of history to see how psychiatry has pathologized LGBTQ+ communities, in addition to many other minoritized groups. To be fair, psychiatry can’t be blamed for the entirety of the problem. Any professional field operates within a culture, and psychiatry is no different.

However, psychiatry is unique in one important way—

--it holds a dubious position of acting as an authority on whether certain behaviors are valid or pathological. And THAT position is one that must be wielded very carefully.

Historical Baggage

Psychiatry's complicated relationship with minoritized groups is not a relic of the distant past; it still affects practices and perceptions today. From the era when homosexuality was classified as a disorder in the DSM until 1973, to the continued challenges around the medicalization of transgender identities and mental health gatekeeping access to care, psychiatry has been used as a tool to enforce cultural and social norms.

The legacy of pathologizing queer communities, where nonconventional identities were once viewed as disorders, has left a residue of understandable distrust and skepticism towards psychiatric professionals.

So--when it comes to working with trans and gender diverse communities, psychiatric practice therefore involves not just clinical competencies and basic cultural humility, but also a deep recognition of the historical and systemic barriers that have shaped patient care, and our field as a whole.

It’s critical that we hold space for that in the clinical relationship, respecting the adaptive nature of a patient’s wariness or hypervigilance. That behavior makes sense when you understand the deep context for it, and in these communities, there’s quite a lot! 

Psychiatrist Richard von Krafft-Ebing, author of Psychopathia Sexualis in 1886, containing many new ideas about the inborn deviance of queer people

Principles of Affirming Psychiatric Care

I could say a lot about what not to do, and I do that in the courses at my gender IQ. Here, I want to focus on what TO do. Affirming psychiatric care is not just about avoiding harm, but instead actively contributing to the empowerment of our gender diverse patients.

A gender-affirming approach to psychiatry is characterized by several key components:

Respect for the Patient’s Autonomy and Knowledge:

Patients are experts in their own lives. An affirming practitioner acknowledges this expertise, viewing the therapeutic relationship as a collaboration rather than a hierarchy. Patients always have the option to get their care outside the medical system, and often do just that when we aren’t trustworthy.

Responsiveness to Change and Individual Needs

Medical and psychiatric communities are slow to adapt to societal changes. Affirming care requires practitioners to stay informed and responsive to the evolving understandings of gender diversity, and know that our patients are more up to date than the research will be. We need to listen closely to our patients.

Consciousness of Biases

Every practitioner has biases; what matters is the awareness and management of these biases to prevent them from influencing clinical judgment. Self-reflect, read, listen, and consult with others.

Cultural Competency & Baseline Knowledge

A deep understanding of the nuances of TGD experiences, including the implications of hormonal treatments and surgeries in psychiatric care, is crucial.

Rigorous Humility

It is essential for us to communicate clearly and humbly, admitting when they do not know something and being open to learning from their patients and peers. I deem this “rigorous humility” because I believe it is a dedicated practice we must devote ourselves to continually.

Moving Forward with Allyship

Embracing a truly trans-affirming approach to psychiatric care requires a foundational shift in how we perceive and interact with our patients, as well as how we critically analyze our training. We must question our assumptions, listen more deeply, and act with both compassion and conviction. True allyship in psychiatry, therefore, involves more than just adopting new terminologies, putting pronouns in the patient demographics, or copy/pasting inclusive policies from the latest training.

It’s a philosophy of care that opts into living in tension between research evidence and community wisdom, and a practice of rigorous humility that can transform how we think and act. 

To learn more, explore these courses designed for psychiatric providers.

The Psychopharmacologists' Deep Dive: Trans-Affirming Care & Hormone Treatment - Extended

The Enlightened Healer: Liberatory Practice with Gender Diverse Communities

Jess Romeo (he/they) is a transmasculine psychiatric nurse practitioner and clinical social worker in the DC metro area. He owns a private practice and is the founder and CEO of my gender IQ, providing education and mentorship on gender diversity to mental health clinicians, group practices, and small businesses.