Keywords

Introduction

Given the high rates of mental health concerns among transgender and gender diverse (TGD) youth (see Chap. 9), these young people may require acute psychiatric care, including treatment in inpatient, partial hospital (PHP), and intensive outpatient (IOP) settings.

Growing up within a body that is developing in an incongruent manner to one’s gender identity can create significant stress for transgender and gender diverse (TGD) youth. Adolescents who experience dysphoria related to this incongruence suffer high rates of internalizing psychopathology that may lead to inpatient psychiatric hospitalization [1]. It is reported that 40% of transgender adults have attempted suicide, of whom 92% report attempting it before the age of 25. Historically, growing up in a culture where minoritized populations experience direct and indirect stigma and discrimination is demonstrated to create significant stress and is linked to poorer health outcomes for TGD persons. Rejection from family and peers, discrimination, bullying, and threats of violence all can contribute to worsening suicidal ideation and serious psychological distress [1].

Acute care in the psychiatric setting can either offer support or invalidate this already vulnerable population. TGD people are at higher risk of coming across challenges in accessing health care, as well as encountering health-care systems that are not geared toward recognizing, validating, and supporting their gender identities. While the immediate priority of the inpatient psychiatric hospitalization is, therefore, first and foremost to ensure safety, providing a gender-affirming environment is paramount in laying the foundation for these youth to continue being engaged in care, rather than invalidating their identity, which could discourage them from seeking care after discharge. Invalidating experiences can be traumatizing for these youth who may enter acute treatment already at higher risk for suicide with comorbid mental health concerns.

This chapter discusses

  • Key ways in which psychiatric systems may create an affirming environment at the policy and organizational level.

  • How inpatient units and hospitals environments can be affirming, including a perspective on how staff can be trained to be effective in this context.

  • Clinical considerations that may inform the individual care of TGD individuals in crisis.

An Affirming Environment in the Broader Treatment Environment

Embarking on the mission to create a safe and affirming PHP, IOP, or inpatient treatment environment for patients in the LGBTQ+ communities can have its challenges, but the reward of working around these challenges is great. In a perfect world, an agency would have full control over all factors of patient care; however, more often, the reality is that agencies begin this mission with suboptimal circumstances that are not easily influenced due to internal agency problems and/or broader healthcare system-related issues. This does not mean that the charge is futile. Success is attainable if the organization is committed to the mission of providing safe and affirming care, and if the agency problem solves creatively and plans ahead for potential road blocks. Of those organizations who do make a verbal commitment to improvement, unfortunately many do not succeed in the actual mission of providing LGBTQ+ informed care.

In order to stand out as a leading organization that does succeed in providing affirming healthcare, an agency should focus on three major areas: physical environment, staff education and engagement, and continued accountability [2].

Physical Environment

The overall goal when it comes to revamping the hospital’s physical environment – whether it be an inpatient unit, PHP, or IOP – would be to modify the space in a way that promotes a welcoming, affirming, and safe setting for patients and visitors. Although the infrastructure of the building itself is not something that can often be altered, there are cost-effective modifications that can be made that do not include pricey renovations. If an agency has funds to spend on physical modifications, there are more expensive alterations that provide ideal benefit.

Modifying physical settings to provide accessible and safe bathroom options is an initial and critical start to greeting TGD youth and families. When single-occupant bathrooms exist on the premises, changing all single-occupant gender-based bathroom signs from male/female images to “all-gender” or “gender-neutral” images is an example of a low-cost modification. Doing so will create a welcoming atmosphere when patients enter new settings in crisis. A more costly approach would be to add single-occupant bathrooms if none exist on site.

Many organizations have multiple-occupant gender-segregated bathrooms which can pose both safety and privacy concerns for transgender individuals. Organizations can consider changing these bathroom types to all-gender restrooms even when there are single gender-neutral bathroom options on site. In keeping safety and privacy at the forefront of decision-making, there are several safety/privacy enhancements that the Human Rights Campaign recommends to aid in this goal (all of which vary in price); install flaps on the outer edge of stall doors to cover the gap between the door and the stall wall, extend stall doors and walls from floor to ceiling, and extend privacy dividers between urinals further out from the wall and to a higher level [2].

Establishing LGBTQ+ friendly resource centers in public areas with materials supportive to gender affirmation will not only provide useful education but will also demonstrate the hospital’s support and competence in this area (little to no cost). Expanding upon the décor of the hospital to include artwork that embraces gender fluidity or diversity can be appealing and within a reasonable price point. Integrating safe zone images throughout the space (printed images at little to no cost that represent a safe and confidential space or person that welcomes people as their authentic selves) will send a visual message that people can discuss a variety of topics without fear of discrimination or retaliation [3]. There is no one set standard when it comes to safe zone signs. An agency can print images that already exist online or create a safe zone sign that relates to their own organization. Another way to display the standard within an organization that gender identity should not be assumed is to provide staff and patients with the option to display the pronouns they use on them with either a pin or a sticker.

Staff Engagement and Education

Agencies can create a culture that supports affirming care by starting with clear and consistent messaging and expectations about what it means to offer affirmative care. An agency may be successful in implementing that care and reaching goals by providing education and resources for staff to carry out this mission. Leadership can create institutional cultural improvements by offering: fundamental training for all staff, training on the latest medical record documentation, advanced clinical training for all clinicians, and consistent evaluation of the patient experience and staff success.

Fundamental training includes everyone employed at the agency – from the first telephone encounter to discharge planning. Training begins with a review of appropriate terminology and concepts and with a discussion of affirming care. Training should offer opportunities for staff at all levels to be aware of their part in creating an affirming environment.

As this is a rapidly changing field, where concepts and terminology change regularly, initial education begins with updating staff on what we currently understand about gender identity and gender expression. While it is human and understandable for employees to come to work with their own biases and opinions, staff members have professional treatment responsibilities as it pertains to patient care and will need to monitor and manage their own biases at work. To assist with this, staff can be led through trainings that explore how personal biases could potentially interfere with their success in providing affirming care. Training may address assumptions we make about gender in our everyday language, ways people can adjust language to avoid assumptions (Fig. 11.1), and ways people can respectfully apologize if they make a mistake.

Fig. 11.1
figure 1

Key points on language

Full size image

All staff will need to commit to asking every patient the name and pronoun they use rather than making assumptions. Although this practice may feel controversial for some, making this routine is crucial if an agency is committed to providing affirming care. There is no way to know someone’s gender without asking. Incorrect assumptions make for a traumatic patient experience and are contradictory to the overall mission.

A common concern is that one could offend a cisgender patient by asking their gender. If the true goal is to provide affirming care, is it not far better to explain to a cisgender person why you asked them their gender than to make an incorrect assumption and offend a transgender person? An example of a response that would be appropriate is as follows: “I apologize. I did not ask you that to offend you. We as an organization will not assume anyone’s gender based on our own assumptions. We ask every single patient to tell us who they are rather than us assuming.”

Teaching staff how to ask questions about gender identity as well as role-playing potential scenarios with staff can help them feel confident and prepared for all potential interactions. Having staff introduce themselves to all patients using their own name and pronoun will act as a model for any patients who do not understand gender identity and will lead to opportunities for staff to spread the appropriate message about gender. It will be helpful to provide staff with a variety of practice scenarios to prepare them for potential interactions about gender so that they feel confident in these circumstances; apologizing for their mistake or redirecting an individual who is being disrespectful, clarifying gender identity for someone who does not understand, etc.

Reputable resources should be provided at the conclusion of these trainings, which will allow employees to do further research from reliable sources if they so choose. National organizations such as Pride, Youth Pride, The Health Equality Index, The National LGBT Health Education Center, Fenway Health, LAMBDA Legal, TGI Network, PFLAG, and the Human Rights Campaign are reliable options.

Creating a TGD responsive electronic medical record (EMR) is a large and system-wide task. In an ideal setting, documentation would be streamlined with clear standards that incorporate the diversity of gender identities, names, and pronouns. Many EMRs do not allow for flexibility in documenting on gender as gender is considered an identifier for insurance companies. In many settings, it may not be feasible to upgrade programming; therefore, creating affirmative work-arounds in the original EMR may be created and implemented systemically by staff. Attention to paper documents given to patients that ask them to select gender may be adapted to include more than the binary male/female options. Establishing responsible persons in EMR administration who will serve as a change leader can ensure that organizations stay up to date with best documentation practices since standards are ever evolving.

Advanced clinical trainings should be delivered to staff that have more of a clinical role with patients (physicians, clinicians, nurse practitioners, etc.). Discussion points on gender diversity, the different ways people affirm their gender, minority stress, biopsychosocial risk factors, and the most up-to-date clinical interventions will be vital. World Professional Association for Transgender Health (WPATH) is a reliable source that provides clinically relevant trainings on these topics.

Unfortunately, even with the installation of the above-mentioned levels of in-house training, it is unrealistic to expect that an agency full of experts on this topic will result. It will be pertinent to seek out in-house leaders; staff members who show a special interest in affirming care. Offering these leaders additional external continuing education training so that they can keep up with the ever-changing and evolving information on gender will be a great benefit to the organization as a whole. These agency point persons will be able to share the most up-to-date information with other employees, and they will serve as a motivating presence in the workspace as it pertains to affirming care.

Continued Accountability

While it is important to focus attention on the physical environment and staff education and engagement, in order to ensure success and stand out as a leader in affirming care for TGD individuals, close monitoring of the patient experience and staff conduct will be paramount. Feedback on patient experience is essential in determining areas of strength and weakness within an organization. Offering a posttreatment survey focused on the affirming experience is a considerate way of eliciting feedback from patients in an anonymous and voluntary manner. It would be helpful to consider establishing an in-house committee to monitor survey feedback and collaborate on solutions for areas of concern. Instituting conduct objectives within an employee’s traditional job evaluation that highlights their own personal role in providing affirming care will allow management to hold staff members accountable and to assess for strengths and areas of potential improvement for each staff person. This will also reinforce the message to all employees that affirming care is the standard within the organization.

Inpatient Settings: A Case Study in Achieving Culture Change

An inpatient environment should seek to affirm the gender narrative described by the patient to allow them to receive the best possible psychiatric care. In order to facilitate an affirming inpatient environment, it is necessary that clinical staff are not only educated, but that there is a collective commitment to the mission. It is critical that unit leadership seeks to assertively develop and support an environment in which gender diverse youth may thrive; at the same time, this will not be successful if clinical staff is left behind by the process. On our inpatient adolescent unit at Butler Hospital, this was achieved through a multistep process that was both gradual and assertive. Core principles were as follows:

  • Exposure and Education: Experts in the area of pediatric gender were invited to speak to clinical staff on multiple occasions. This was combined with implementing lessons learned as relevant clinical situations occurred.

  • Crucial Conversations: Clinical staff were engaged around their own preconceived notions and potential areas of bias, and these were anticipated and addressed prior to patients arriving on the unit in order to ensure that barriers to affirming care were resolved without impacting the experience of individual patients. This approach drew on the concept of “crucial conversations” – a set of techniques for having productive discussions around emotionally charged topics [4].

  • Staff Engagement at All Levels: Responsibility for an affirming environment was shared between physicians, nurses, mental health workers, occupational therapy, social services, and administrative staff. This approach reflected the principles of “shared governance,” a well-articulated approach to manage complex challenges in professional environments [5].

  • Implementing Agreed-Upon Changes in Steps: New approaches (e.g., bathroom or room assignment based on identified gender) to address TGD-specific needs were implemented in response as clinical situations arose, allowing staff to process barriers and participate in a collective effort to support gender diverse youth.

With these guiding principles, change was achieved through the following staff development procedures:

  • Case Studies: These included an existing space for weekly, multidisciplinary case discussions and to identify areas for improvement in affirming care. These case studies provided an opportunity to identify preconceptions and bias and provided a safe platform in which these barriers could be explored and processed.

  • Informal Educational Interventions: These include ad hoc conversations regarding appropriate pronoun usage and open-ended conversations to understand the current beliefs, level of understanding, and skill of individual staff in supporting gender diverse youth.

  • Formal Educational Interventions:

    • Nursing grand rounds – A four-hour training was provided by a local physician expert on best practices for supporting gender diverse youth, for which continuing education credit was available.

    • Staff meetings – Additional trainings were provided by unit leadership, which utilized the Joint Commission LGBT Field Guide [6].

    • Optional trainings – Staff were encouraged to take the training offered by the Human Rights Campaign 2018 [2], which was made available for free through an institutional license.

  • Continued Education: Existing platforms for clinical discussion such as weekly rounds, staff meetings, and weekly case discussions were thoughtfully enhanced to provide ongoing reinforcement of principles expounded during more formal education approaches

Practical Approaches

Achieving an affirming environment required both institutional change and circumventing complex challenges with practical solutions. It is possible to facilitate an affirming patient experience, even if longer-term challenges remain in addressing structural sources of bias within medical systems. The following steps were taken on our inpatient unit:

  • Name and Identifiers: As noted previously, institutions vary in their ability to consistently display preferred names in electronic medical records, and regulations require that legal names appear on certain forms to facilitate inpatient admission, consent to care, and insurance. In order to balance this limitation with an effort to create an affirming environment, asserted names can be displayed on areas visible to the patient, which do not constitute legal documents – such as the unit name board, and whenever names are listed for unit activities. Staff can reference these sources where reminders are required regarding patients asserted name. Individual clinics and providers may be creative in work arounds that include patients asserted names being listed on wristbands, as this may be a low-risk opportunity to provide affirmation.

  • Bathrooms: In order to maximize the positive experience of all patients while providing an affirming environment, communal bathrooms were used and gender diverse youth were allowed to use the bathroom that they were most comfortable with – an approach which has been implemented without incident over the last several years.

  • Room Assignment: Preferences of the patient, the desire to be affirming, and the needs of other patients were considered and weighed. Although it may seem optimal to always room patients with other patients of their affirmed gender, this does not consistently reflect the desires of patients or may be challenging for other reasons. A single room is frequently a stated preference for gender diverse youth who are undergoing hormonal or surgical changes, and this is made available in these instances. Youth who have not begun any hormonal or surgical intervention may be most comfortable with roommates of their assigned at birth gender. When gender diverse youth express a desire to have a roommate of their affirmed gender, this should be facilitated as long as it does not expose the patient to undue risk; patients may experience trauma if they are roomed with a peer who articulates stigmatized views toward the patient. Available guidelines for Lambda Legal suggest that where patients object to having a gender diverse roommate, this should be problem solved through a discussion with the patient, or moving the patient who expresses the concern [6, 7]. In practice, we have found it is almost always possible to provide an environment, which is affirming, safe, and therapeutic for all patients.

  • TDG-Affirmative Resources and Materials: The physical space included resources and materials for youth to see examples of gender diversity and to explore their own gender. Developmentally appropriate and affirming materials are made available, which provide concrete explanation and facilitate exploration of a patient’s individual gender narrative.

Ongoing Challenges

Much work remains to be done to ensure that gender diverse youth have more consistent access to affirming inpatient care. Even within an environment, which seeks to prioritize this mission, challenges remain:

  • Barriers: Privacy laws may be violated if potential roommates are made aware of a youth’s gender diversity; not involving the roommate in such a discussion creates a real risk for inappropriate comments or behavior toward the roommate should they come to this realization in other ways. Parents of both patients and roommates may not hold affirming views around gender diversity, and it may not be in the youth’s best interest for this to derail psychiatric treatment.

  • Personal Bias: Despite intense efforts at education, there may be areas of ignorance and a lack of commitment to an overall “culture change” among staff.

  • Issues of Intersectionality: Youth in mental health settings may experience an intersection between their gender-related concerns, mental health concerns, and other socioeconomic factors that impact long-term health outcomes. More clinical study is indicated to best inform how to balance attention to the gender narrative during periods of crisis in order to optimize mental health treatment and ensure that youth receive the best care. Taking the lead from the patient seems to be a promising approach to this challenge – this is discussed in further detail below.

Clinical Approach

As there may be different reasons why a young transgender youth would find themselves in an acute treatment setting, there may also be a variety of unique gender issues specific to each patient.

TGD youth may disclose gender dysphoria or their transgender identity for the first time during the course of hospitalization or intensive outpatient care. This is more likely to occur if they have formed a trusting relationship with their clinician. These youth may be engaged in the process of exploring their gender identity and what it means to them. There may not be a commitment or crystallization of their gender as of yet. For these youth, it is important to not impose an artificial burden of having to make a decision about their gender. A clinician’s best work is done supporting this process of emerging identity and allowing them a safe space to explore their gender identity. Relevant information regarding important and emerging aspects of gender may be communicated to staff and their outpatient team. Some youth may request more information and resources and referrals to gender-specific services as they approach discharge. Knowing your community providers and allies may help facilitate these next steps.

There are also youth who experience fluctuations in their gender identity or consider themselves outside the gender spectrum (i.e., nonbinary). These nonbinary identities may be encountered during acute treatment. Some fluctuations may arise when patients experience unsupportive attitudes and bias [8]. Nonbinary youth also tend to experience less support from their family and friends, putting them at greater risk for suffering [9]. Some youth experience understandable ambivalence about the cost and hardships encountered during the process of undertaking gender-affirming steps and long issues that may arise. Some youth do not continue to identify as transgender into their adulthood [10]. Regardless, having a safe environment and trusted relationships in which to discover who they are is the key component of any psychiatric treatment. In case of multiple psychiatric hospitalizations or periods of PHP/IOP treatment, where the patient has demonstrated variance in their gender identity or gender expression, clinicians and staff should maintain a nonjudgmental and validating approach toward the patient. Educate staff members that this variance may be a normal part of exploring gender identity for some youth. It is not necessary that one particular gender will be adhered to as part of the process of discovering one’s most authentic self [10, 11].

There are other transgender youth admitted to acute care settings who are clear about their transgender identity and have not yet disclosed it to their family. In such cases, it is important that the clinician openly discusses what the young patient is comfortable disclosing to their family and when. Here, the role of the clinician is to support the patient while facilitating a discussion to enhance the family’s understanding of the youth’s gender identity. Often parent support and guidance are needed after the disclosure. The family should be supported in processing the information as they come to a place where they can mourn the loss of the idealized child and be more welcoming and accepting of the real person in front of them [8]. Understanding the family dynamics and environment in which the youth will be discharged is key in safe discharge planning.

Helpful Tips for Disclosure

  1. 1.

    Create a therapeutic alliance with the parents.

  2. 2.

    Inquire about the parental experience of their youth’s journey. Often parents are already aware of the TGD youth atypical journey of gender development.

  3. 3.

    Explore parental beliefs about gender diversity and human development based on their social, cultural, and religious background.

  4. 4.

    Support the TGD youth when they are ready to disclose to their family, based on the individual youth’s expressed needs.

  5. 5.

    Create a safe space both for the TGD youth and family to process together and individually. Set a supportive and nonjudgmental tone that does not stigmatize the TGD youth.

  6. 6.

    Provide psychoeducation to the family. Clarify that gender diversity is a normal human expression. It is also helpful to discuss that various trajectories such as persistence, nonconformity, phasing out, or adoption of atypical gender expression cannot be predicted.

  7. 7.

    Highlight the important role of parental support and involvement with the TGD youth. Although they do not influence their child’s gender expression, they have a much greater influence on their physical, emotional, and psychological well-being, and social adjustment

  8. 8.

    Provide support in case of parental crisis. Explore parental fears.

  9. 9.

    Make a plan with the family to provide safety and support for the TGD youth.

  10. 10.

    Make referrals for family therapy and marital therapy if indicated.

There are instances when transgender youth are not ready to disclose their transgender identity to their family just yet. They may have previously experienced an invalidating environment or other forms or trauma or abuse that makes it difficult for them. Here the clinician must take the patient’s lead. The focus should be respecting the patient’s autonomy while helping them to build resilience to cope with the outside world and gain a greater sense of empowerment. Referrals and resources that are gender affirming outside the family setting can be helpful. Gendercool Project, the GSA network, Campus Pride, and Youth Policy Institute (YPI) are some examples where TGD youth can connect with peers and access support for themselves. It is also essential that the patient preference is seamlessly communicated to all members of the team involved in taking care of the patient, to ensure inadvertent disclosure does not occur.

As with their cisgender peers, TGD youth may require acute psychiatric treatment for a variety of mental health needs. Thorough psychiatric assessments for anxiety, mood, and substance-use disorders along with trauma are necessary and should not be overlooked [12]. Transgender identity can at times serve as a focus for other displaced conflicts, whether with their family, peers, or themselves. In some cases, there may be additional stressors that can compound the experienced minority stress, while in other cases, preexisting mental health issues can surface as result of the difficulties the TGD youth is experiencing. It is important to explore these both independently, and as they relate to the TGD identity [13]. Focusing on appropriate treatment modalities for comorbid disorders should be integrated into gender-affirming care and prioritized based on severity and impact on the individuals psychological and social functioning.

Psychopharmacological intervention may be indicated as part of the comprehensive treatment plan to alleviate symptoms of anxiety and depression that can result from minority stress and internalized bias, particularly when they impair functioning. It is also ideal to access appropriate consultation when indicated for psychoeducation about gender affirmation, hormonal therapy, and surgical interventions. The acute care setting is well suited for a multidisciplinary meeting to address these issues with the family while drawing in expertise from clinicians who will continue to follow-up with the patient after discharge. Questions may arise as to the timing of hormonal therapy for which input from a physician who specializes in these treatments can be extremely helpful. The treatment team should facilitate discussions as the next steps toward gender affirmation are discussed in a way that is most appropriate and supportive.

TGD youth in acute treatment settings deserve a full risk assessment upon admission and discharge, as well as developing a conceptual framework of their social and familial supports. A thorough discussion of a safety plan as well as follow-up treatment should be undertaken with the patient and the family. There is indeed an opportunity to take the time and holistically view the needs of the TGD youth and to make referrals that will best support the patient. There is now greater initiative in establishing specialized programs for LGBTQ youth in order to better address their mental health needs in a gender-affirming environment. Coordination with the school may also be necessary for those youth requiring academic support or interventions in the school environment.

Additionally steps should be taken to set up social and community supports for the transgender youth. As mentioned earlier, PFLAG, Campus Pride, Camp Aranu’tiq, the Trevor Project, and others serve as great resources to make these connections. Online resources can be accessed through www.genderspectrum.org.

Conclusion

Transgender and gender diverse youth face an unfair problem; although they may have greater needs for acute mental health treatment, they are less able to receive this treatment in environments that are appropriately supportive. Although practical challenges exist, there are many opportunities to create both small and larger institutional changes that would benefit these youth and families, educating and developing staff and clinicians who have the necessary skills to treat mental health concerns, while supporting and affirming the dynamic process of gender exploration.