Hello everyone, welcome. Thank you for your attention. Once again, I'm Chris Blazes. And on behalf of the American Academy of Addiction Psychiatry, welcome to today's webinar and our Advanced Addiction Psychotherapy curriculum. And once again, as most of you know, this is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry and fellows and faculty throughout the country. We record lectures on various psychotherapeutic topics, and they're available for subsequent viewing. This is hosted in partnership with Oregon Health and Science University, which is where I'm located, as well as NYU, which is where Dr. Sickler is. We're excited that you can join us today, and we offer these live trainings, and they're held on the second Wednesday of each month from 5 to 30 p.m. to 7 p.m. Eastern. Today's presentation will focus on the transgender patients, and our next presentation will be in June with Dr. Lois Choi-Cain, and she'll be talking about good psychiatric management for borderline personality disorder and alopecia. So please check the AAAP website for updates and other upcoming speakers. And so now I will pass it off to Dr. Sickler for the introduction. Thank you, and again, we're very happy to have Dr. Johnson here with us today, so I'll give you a little bit of his background and experience. He's a clinical professor of psychiatry at the Norton College of Medicine at SUNY Upstate Medical Center, where he is also the academic director of the Addiction Fellowship and also serves as a staff psychiatrist at the Pomeroy Addiction Treatment Center at Crouse Health. He's been evaluating and treating transgender, gender-diverse, and non-binary patients of all ages for over 10 years, having given lectures and talks on this topic as well. He's one of the authors of the chapter on substance use disorders in the recent publication, Gender-Affirming Psychiatric Care, available through APA Publishing. He has served as a board member for the Trans Bodies, Trans Selves, a resource for the transgender community, as well as the editor for the second edition of the textbook of the same name, which was published in 2022. And finally, he's a member of the WPATH, or W-P-A-T-H, which is the World Professional Association for Transgender Health. So we're really looking forward to this talk, and I'll turn it over to you, Dr. Johnson. Thank you very much for having me. This is great. So yes, again, I'm Dr. Johnson, Kevin Johnson. So I use all pronouns, which I'll talk about in a minute, except no disclosures. And an overview of the talk today. So I typically like to start these talks off with a trans 101, just to make sure that we're all on the same page when it comes to identities and terminology. Then I'll go into some of the data that we have so far on substance use and addiction in transgender and gender diverse communities that we have. It's very limited, but there's enough of it to talk about. Then I'll move on to talking about models of addiction, because oftentimes people ask why, why is there such a high prevalence of addiction in trans communities? But then I'll move on to the treatment element, starting with the role of a psychiatrist in working with trans patients and some barriers that warrants us to address when it comes to working with trans patients in the context of our historical narrative. And if there's time, I'll give a little information about medication-assisted treatment and its potential interactions with gender-affirming care. Though if I don't make it there, I'm happy to provide the information. It's also in the chapter in the book that was mentioned in the introduction. So when it comes to gender identity, there are four main words that apply that's important to know, and that's gender identity, gender expression, anatomical sex, and sexual orientation. Gender identity is the mind, it's identity, whereas anatomical sex is something that's more physical, you know, so anatomy, chromosomes, hormones. This is a copy of the gender of a person. When I talk to patients, I love using this model. It's free online. There's different versions of it based on one's experiences, more advanced level, and there's a more basic level for those who are just learning. And what it is, is it's a person that allows you to explain how each of those four concepts can be different and placed on a spectrum or a binary of sorts, with gender identity being, you know, the element of manness and womanness, along with anatomical sex, maleness and femaleness. And so the concept of trans is essentially when one's gender identity does not match the anatomical sex, or in many cases, the anatomical sex assigned at birth. And the thing with gender identity to keep in mind is that A, it's not the same as sex. And gender identity is a social construct, meaning that even though there's a lot of data that focuses on gender identity, there's a lot of other data to suggest that it's something that our society creates. Some of that data involves looking at gender in other cultures. So for example, in Hawaii and Tahiti and various other Polynesian islands, there's a third gender called mahu, which is a kind of a Hawaiian version of non-binary, but with more spiritual conceptualization behind it. Oftentimes those who are mahu have components of both male and female genders, and oftentimes serve as a intermediary between the two in a very spiritual and revered context. Hijra in South Asian countries, India, Bangladesh, often is also seen as a third gender, as well. Often those who are assigned male sex at birth, but have a feminine gender presentation. And then Indonesia, this culture has five different gender identities, ranging from male and female in the binary to feminine males, masculine females, and everything combined. And I'd be remiss to not mention two spirits in the first nations of North America, and many different cultures. It's another conceptualization of their gender where there's variations of gender expression and gender identity on the inside. Now, when it comes to language and terminology, a lot of people like to call this the alphabet soup. And the reason why a lot of these terminologies exist is to be as inclusive as possible. So I mentioned before that transgender mentions the difference between anatomical sex or sex assigned at birth and gender identity are different. However, transgender itself as a umbrella term, which can be used as an umbrella term in any context, sometimes leaves out people who are non-binary or have no gender or whose gender are outside the binary. So you'll see terms like gender and gender non-conforming, gender expansive, gender diverse, or transgender and non-binary gender diverse as ways to be as inclusive as possible. I often tell folks that this is not made to confuse you. It's not meant to hurt conservative people's feelings. Its main purpose is to be as inclusive as possible for as many people as possible. And you'll see a lot of these acronyms being used interchangeably, including in this presentation, to be frank. I typically stick with the TGD, transgender and gender diverse, just because I think it sounds better. AMAB and AFAB are also important terms, especially in the health clinical context. So refers to assigned male sex at birth and assigned female sex at birth. And this is based on the concept that you really can't ask an infant what their gender identity is. All you can do is look at their anatomy, maybe assess their chromosomes and get a sense of their anatomical sex, which is assigned at the beginning, which may or may not change as they get older. Gender modality is a relatively new term. So gender identity as a term has been helpful, but also has some restrictions as well. So when you talk about gender identity, are you referring to someone who is a trans woman or someone who is a cis woman? If you have a gender identity as a woman. Gender modality refers more to the concept of if you're a trans or cis. So if you're trans, your gender modality is trans. It doesn't matter if your gender identity is man, woman, or something else. Cisgender is basically not transgender. And then non-binary, which has been in greater and greater usage over the last five years or so, refers to folks who just are not on that gender binary of man on one side and woman on the other. And there are a ton of other terms, gender variant, genderqueer, agender. I have given up trying to memorize and learn all the terms because it grows and changes with time. And again, the point is to be as inclusive as possible and to learn about people's experiences as much as possible. But I also say that language matters when it comes to working with patients, because as patients start to get to know you, it's important to have an understanding of how you can have them feel safe in the clinical encounter. As I'll talk about later in the presentation, healthcare providers have a really bad reputation of being pathologizing, being discriminatory. So all that baggage will come with you to the patient encounter. So oftentimes patients will look to the language that you use as a means of, is this person safe enough for me to disclose personal information to? And the other thing as well, I don't want to create an environment where people are afraid to talk or are afraid to make mistakes. Mistakes happen. So it's okay to make mistakes. It's just more being aware that these terms exist for a reason and it's important to learn them and learn them with the patients. Now, a lot of the language that has been used in the medical context can fall under one or two constructs of gender identity, the medical constructs, and then the individual construct. So just to give an example of a narrative. So under the medical construct, someone will be born with a male sex, having male genitals. And then as they get older, they transition to become women through a sex change operation and are considered an MTF or male to female, transgender, transsexual. The focus is on the genitals and where they are at birth and what you can ascertain from their physical sex. Whereas the individual construct focuses more on the mind and the gender identity itself. A lot of studies have backed up the concept that gender identity solidifies around age three to five. So it's something that's been present for a long time. Sometimes folks don't realize it until they're older, maybe around puberty or sometimes beyond that. But that same narrative that talked about before, that same person was assigned male sex at birth as a female gender identity that developed at an early age. Then as they're older, they have gender confirmation surgery, a gender affirmation surgery to match their body with the gender identity they had in their mind the whole time. And as you can see with the table below, a lot of the terminology that you may hear people say can fall under one of the two constructs. I try my best to fit things under the individual construct, just because there's more data to back that up. And in many cases, it's more affirming for patients to say gender affirmation surgery than sex change operation. And I went talking to patients and asking about it. So this is a screenshot from one of the intake forms that I give patients when I first meet them. And this actually comes from a study that was done in a primary care setting with different listed gender identities, along with sex assigned at birth to then pronouns. Now, note that I put down other for both gender identity and pronouns to allow people to write down what they felt comfortable with. The challenge is coordinating this with the electronic medical record if you have one. But this is how I typically introduce the topic. Another thing that I do clinically is when I work with patients, I often start out by giving my pronouns. And oftentimes, that opens a door for patients who wonder, OK, this person knows enough pronouns to introduce themselves with their pronouns. So let's speak and talk about gender issues. And on the subject of pronouns, so the English language has three cases, nominative, objective, possessive. So we have different elements of pronouns. In English, it's gendered. And so there have been changes in terms of pronouns that are not on the binary. So the singular they has been in use more and more over the last 10 years. And a lot of people like to complain. I haven't heard it as much lately. But the concept that the singular they is grammatically incorrect or it's too confusing. But the singular they has actually been in use since the 14th century, before the time of Shakespeare even. So this is something that's not new. And this trend towards the use of a singular they or gender neutral pronoun, it reflects a trend over the last several decades of making the English language more gender inclusive. So it not only includes pronoun usage, but also the trend towards making words less gendered, such as actress, or policeman, or stewardess, instead of using the word actor universally, regardless of gender, or police officer or flight attendant. And then when it comes to asking about pronouns, so it used to be acceptable 10 years ago to say, what is your preferred gender pronoun? However, the challenge with the word preferred before pronoun implies that gender identity is somehow a choice. It's kind of similar to why a lot of people don't use the phrase sexual preference, because it implies that you think that sexual orientation is a choice. Even though sexuality can be fluid, just like how gender can be fluid, again, it's the perception of the use of the word preferred that can be a challenge. Also, when I talk to patients, the other element with pronoun usage and gender identity is what goes in the chart. Because I have a lot of patients that come to me, I work in a large health system that includes primary care, specialty services, some of them have access to my chart, some of them don't. So I often have a conversation with patients, especially as they're trying to figure things out. Do we use this pronoun in the chart? Do we use it here? What would you feel comfortable with? Because if I put it here, do you want your primary care person to know about this versus not? I seldom encounter folks who say, well, I can talk to you about it, but not to this other person, unfortunately, but I always have that conversation just in case. Just a sample question. So 19-year-old new patient, Chris, who presented to the ED with new onset fever, rhinorrhea. On presentation, Chris appears androgynous and you're unsure what pronouns to use. What's the most appropriate course of action? So A, check the sex marker in the chart prior to the encounter. B, ask what pronouns the person prefers to use. C, introduce yourself by stating your pronouns and follow up by asking what pronouns to use for themselves. D, avoid using pronouns altogether. Or E, ask the nurse who screened the patient about pronouns. So I'll give you a few seconds to think about it. So the answer is C. So introduce yourself by stating your pronouns and then following up by asking what pronouns they use for themselves. The main reason why it's not B is the word prefers that's in there. But I always say that it's always helpful to start off by offering your own pronouns because it's, in some cases, common courtesy. And when it comes to epidemiology, so the question, I got these questions from a CME exercise on transgender health that I think would be relevant to this presentation. But difficulties in estimating the prevalence of transgender individuals are the result of A, the variety of terminology used. B, the differences in presentation. C, a reluctance to disclose because of social stigmatization. Or all of the above. You know, in my experience taking tests, if there's an all of the above, it's usually all of the above. But when it comes to epidemiology, all of these issues pop up when trying to measure, you know, how many folks in a certain population are trans versus not. And there are many ways to do it with many purposes behind it. You know, a 2020 review estimated that there are 1.4 million trans-identified adults in the United States as of 2020, which is, according to the population around that time, about 0.0039%, or 390 per 100k adults. Now, in the VA, they did a study where they looked at charts and which charts had a diagnosis of gender dysphoria, indicating that they are trans on some level, and found the proportion to be six times higher than the national public. In fact, it's a well-known fact that veterans are more likely to be trans than the general public. In the VA, where I used to work, they have quite a few programs available to help veterans to affirm their gender identity. And in Europe, there are a number of different studies that also focus on electronic medical records and found that the proportion of trans women and trans men is about two to one in different countries. But when you ask people directly how they identify, that's where the numbers change for a number of different reasons. And also generational for a number of different reasons. And also generational as well. So a survey in New Zealand high school students found that 1.2% of the students identified with being trans or binary to some extent, which is much, much higher than 0.0039%. And then in a phone survey in Massachusetts, only half the percentage affirmed being trans, but again, much, much higher than what was estimated in the other study. Now, this graph is from a survey of 27,000 transgender adults in the United States, where they asked questions on numerous topics, both with regard to physical health, substance use, and also psychiatry as well. And one of the most used findings of the study was the first bar here. They found that 29% of the respondents reported illicit substance use within the previous month. And this includes marijuana and also non-medical prescriptions as well. And that factor, and that's compared to 10% of the population. So we know from the study alone, that's been used in a number of different places that trans people are three times more likely to have used an illicit substance within the past month. You know, with greater use comes with greater rates of addiction and substance use. And the data also delineates based on the type of substance, including with tobacco and binge drinking being about neck and neck, which is a little confusing because other data show different results. Then with tobacco in general, there is a lot of conflicting data based on what population you study. Some show higher rates of smoking among transgender men versus women. Some show the opposite. Some actually show negligible differences between any trans person or cis people. There's also some studies on youth that trans youth are three times more likely to use cigarettes in school. Tobacco is a pretty hot topic when it comes to the LGBT community, but particularly the T. You know, to have tobacco is often a relative contraindication to hormone therapy, particularly estrogen because of the rest of blood clots. Now that's relative contraindication, not absolute contraindication because there's a lot of debate around using smoking as a barrier to accessing gender affirming care. But with that said, one study did find that in this context, trans women had a much higher put rate of tobacco in the context of using four months in the national average. That's something. And there's also the interaction of smoking with surgeries, all surgeries, but with gender confirmation surgeries, wound healing is very important. And that's what tobacco affects the most. Now with alcohol and cannabis, you know, so a lot of data's have consistently shown heavier rates of alcohol use, particularly binge drinking. And with trans men having a much higher rate of binge drinking and use overall than trans women in the population but in one of the few studies that I found that also studied non-binary populations that's separate from binary trans individuals found that non-binary folks had even higher rates of drinking compared to binary transgender individuals, particularly those who were assigned male sex at birth. There's also a lot of studies that I'll talk about a little later that correlates a lot of psychological and social indices with rates of heavy drinking including abuse both psychological and physical. Now with cannabis there are higher rates of cannabis as well it's been pretty consistent across different studies with trans men using higher rates of cannabis than trans women. Now with other substances so there's been pretty consistent increases among all different substances methamphetamine use in particular among transgender women and also with cocaine as well with transgender women and this applies to adults but also youth as well higher rates of prescription analgesic use among middle and high school students veterans more likely to have a sedative use disorder so there's increased rates all around. Now with behavioral addictions or process addictions this is the hardest area to find the data that would that would help me conceptualize this. First of all there's very little data on behavioral addictions in general. It took me some digging to come up with a statistic that 47 percent of the U.S. adult population has some behavioral addiction with some sort of serious negative consequences which you know falls into the category of an addiction but there are some studies that if you compare them with each other suggest a higher rate of sex addiction you know so 15.1 percent in one study of trans individuals compared to a national average of 3.6 percent but that's from a different study from 10 years prior. A lot of these prevalent studies were really surveys of the trans community to get a sense of how often one has these behavioral or process addictions without directly comparing them to the cisgender population for for comparative purposes but there have been some studies that show you know some levels increased levels of you know levels of exercise food addiction and gambling. Now when it comes to models of addiction so why are trans folks at risk you know why are there higher rates of substance use and addiction in the general public. Now talking about different models of addiction so many people who use substances don't develop an addiction you know a lot of people are able to stop once they start using so why do some people develop a substance use disorder while some do not and part of answering that question is developing a series of different models that have been developed over different contexts different times to explain how addiction develops ranging from a psychodynamic model that use addiction from an attachment theory perspective to something neurobiologic that focuses on specific brain pathways. For the purposes of this presentation though I'm going to talk about the biopsychosocial model which in my mind is the most all-around inclusive and when it comes to biological factors so I couldn't find any data that suggested that you know being trans led to biological risk you know in terms of like brain anatomy or genetic vulnerabilities but the main biologic factor that pops up where there's two is an increased use of using a substance which puts you at higher use of developing an addiction and also higher rates of comorbid conditions so depression anxiety disorders all of those also increase your risk of developing an addiction after using a substance. Psychological factors are where things get more interesting so a lot of the factors fall under a concept called minority stress theory which applies to people in a number of different categories people of color people with disabilities and it's an evidence-based framework that describes the negative impacts of discrimination it can impact mental health self-image in many cases physical health you know blood pressure you know sometimes stroke depending on the population and a lot of the studies on substance use in the trans populations have noted a number of different psychological factors that have been correlated with higher use of substances and also an addiction after the use of those substances so gender-related discrimination also high visual gender non-conformity basically the harder it is to blend in to your general community the higher rate of substance use having intersectional identities also because since minority stress theory applies to different identities if you have you're a trans person is also a person of color who also has a disability your risk of having additional minority stress goes up and the reason why psychological factors exploring them and acknowledging them are important at least in my opinion is when working with patients on a therapeutic level this is where teaching coping skills come in this is where teaching healthy patterns of dealing with the outside world come in this is we're dealing with low self-esteem and building a strong important sense of self-concept one concept that pops up a lot when it comes to minority stress theory is internalized discrimination or internalized homophobia or what as one is exposed to negative stereotypes and discrimination or negative beliefs about trans folks sometimes that can be absorbed and believed by the actual person that I must be this kind of person and then that can lead to low self-esteem and then problems down the line so a lot of the work done in the therapeutic environment is to help reverse that which we'll talk about later now this is from the same study of 27 000 trans folks they asked a set of questions called the tesla six that assessed whether if you are currently in psychological distress not if you ever were in psychological distress if you're current psychological distress right now and they found of all the respondents 39 were currently in psychological distress compared to five percent of the u.s population the general population that was done from another study so we know from this data that trans people are eight times more likely to be in psychological distress right now and younger you are the higher the rate of psychological distress the figure to the right I think is really interesting because they correlated that data with the how deep one is into their transition they let the definition of transition up to the patient and they found that the deeper you're into your transition the lower the level of psychological distress now I'm a huge fan of the saying you know correlation doesn't apply causation but there is an implication that has been backed up with other data that the sooner and one goes into their transition the sooner one gets access to gender-affirming treatment the better mental health outcomes suicide as well as a huge concern as well as in that same study they asked the respondents who has attempted suicide within the previous 12 months and seven percent answered in the affirmative compared to about half a percentage point for the general public so from this we can ascertain that trans people are 14 times more likely to have attempted suicide so not having suicide ideation but an actual an actual attempt now social factors come from a lot of the demographic disparities that also pop up with trans populations higher unemployment rates higher rates of intimate partner violence incarceration sex work homelessness all of these can lead to an increased risk of developing an addiction you know partially because there's an increased exposure to substances but also a lot of the effects down the line from discrimination overall and from a treatment perspective this is helpful to be aware of conceptually because a you know a lot of these are addressed on a institutional or legal level you know whether it's with fighting policy protests changing policies at the hospital you know ranging anywhere from changing the non-discrimination policy to having you know all gender restrooms this is something that's you know on a systemic level other elements of social factors so the community itself sometimes can perpetuate substance use in a number of ways one is you know a lot of social events and lgbt communities take place in bars where there's often exposure to alcohol among other substances and there's also a lot of data that suggests that companies like tobacco companies alcohol companies directly target lgbt communities as a source of income you know and it's it's you know i don't know if anyone's been to the new york city pride parade before but there's a huge float for absolute vodka they just sponsor a float and they advertise it to everybody which goes to show that in this population is targeted quite a bit from from alcohol companies and then going back to that study so they delineated data a little bit more and they separated out those who were trans using substances and working in the underground economy which they delineated as those who were basically working in a job that's under the table or doesn't result in a w2 this could range from sex work to other things under the table and they found that the rates of substance use increased compared to the trans respondents who were not working in the underground economy further suggesting that one's social environment plays a role with exposure to substances and developing a substance use disorder now when it comes to entering treatment you know this is a study from um 2014 um that um surveyed um you know 199 trans folks and almost 13 000 cisgender folks who were in substance use troop to get a sense of what demographic differences um are there between those who are trans and those who are cis and trans women reported greater needle usage and were six times more likely to be seeking treatment for methamphetamines i said earlier that methamphetamines is particularly high among trans women trans men enter treatment at a younger age compared to cisgender men were more likely to be employed more likely to be or less likely to be in some form of legal trouble so sometimes most often motivated by other reasons than legal reasons but we're five times more likely to be living with another substance user within the community and then among all transgender individuals compared to the cisgender respondents they all reported worse physical health problems more mental health diagnoses and were more likely to be prescribed psychiatric medications now what is the role of the affirming psychiatrist so um this is a from a paper that i wrote back in 2018 that you know conceptualized what psychiatrists can do in the role when working with trans and gender diverse patients you know this comes from a number of different sources including my personal experience but also from the w path guidelines which is the world association world professional association for transgender health and it ranges from an assessment gender dysphoria to educating patients and their families about the diversity of gender referring them to other professionals ranging from surgeons to primary care providers homeroom prescribers sometimes electrolysis and i once referred a patient to a voice training seminar that was taught in ithaca for free treating co-existing mental health concerns you know both with medication and psychotherapy sometimes referring out if needed and also advocating being an advocate both you know for your patients individually but also the community as a whole um you know when it comes to both educating other providers or um or in political arenas now from the assessment standpoint there's no standard screening tool or standard assessment that's done to assess gender identity um now what do i mean by assess gender identity what does that mean oftentimes when i first see a patient they refer to me for a letter of support for surgery for hormones and so they're asking they ask me to do an assessment to get a sense is this person appropriate for gender confirmation surgery or to start a hormone therapy for psych clinics that still require letters for that and so oftentimes i really just get to know the patient uh you know ask them about their developmental history and uh you know include questions about gender as they grew up you know what's your first early memory that you can remember with gender and you know that it not that it didn't match what people were expecting you to have when you were growing up uh and keep an open mind you know so a lot of people hear that narrative of you know i was born in the wrong body and i was going through childhood suffering because i really wanted to wear a dress but my mom made me wear pants you and you do hear those stories that are out there um but there are also narratives as well where people didn't have that and their experience with gender were very very different and it doesn't make it any more or less trans so it's important in your evaluation to get a sense of their psychiatric diagnoses um and kind of rule out conditions that could suggest that there's an underlying condition that could be mistaken for gender dysphoria i almost never see this i think in the 10 years i've been doing this i saw this once um but essentially with psychosis or delusional disorders you know oftentimes if you treat that um you know and if their gender identity is consistent then um then their gender identity is consistent um and i um i always caution mentioning this because it doesn't mean that if someone has a psychotic disorder um or body dysmorphic disorder they can't be trans there are many folks who have a diagnosis of schizophrenia or depression with psychotic features who are trans um but it's just something to keep in mind with the differential i'm gonna skip this for now and then in addition to the assessing parts of diagnosing and treating co-occurring psychiatric concerns that may be present um you know sometimes they're there sometimes they're not uh and uh part of the reason why that component is very important particularly for the evaluation is you know it's been well documented that untreated substance use and depression lead to poor surgical outcomes so that's uh you know part of why i conceptualized the importance of screening for that as well but also sometimes patients come to you for that particular reason and gender is just something that's just happens to be part of the picture now i'm going to talk about barriers to building rapport with patients this applies generally in the psychotherapeutic um scenario but this can also apply to medication management or brief counseling um but this refers to the concept that there's a lot of baggage um in the psychotherapeutic encounter particularly at the first appointment um and it's important to be aware of those concepts as you're working with patients particularly because you know because we have a bad reputation a lot of folks who are trans avoid or delay treatment because of fear of being mistreated and in some cases you know the fear could be justified you know there's still a lot of reports of discrimination or deliberately wrong pronoun usage that keep people out of medical treatment uh that keep people out of medical treatment um you know one survey based out of washington dc revealed that among those who had a drinking problem only 36 actually sought treatment and then among um illicit drug users um only 53 percent sought treatment uh so there's um and that could be for a number of reasons beyond fear of discrimination um but um that's definitely a concerning factor because we know that trans folks who have addiction want to get treatment they want to get help um these are the um some of the results from a study from the global drug survey which is a online survey that um asks a pretty consistent set of questions across the world and it's one of the few large-scale substance use surveys that do include questions about being trans or non-binary um and they found that those who are trans were more likely to report the use of substances um their desire to reduce the use did not differ between trans and cis participants um but trans folks were more likely to want help um at least among those who wanted to use less um and then similar with non-binary people who um also reported like a need to help or need to help to reduce use so we know that people are in need of help and actually want that help now there are a number of different barriers um i'm going to talk about three in particular that have stood out you know both in clinical practice and also in the literature um one is gatekeeping gender affirming care which i'll talk about in a minute um othering of trans individuals in our general population and then pathologizing trans identities um gatekeeping in particular refers to the concept that you know we as health care providers are serving as uh barriers or gatekeepers to accessing gender affirming hormone treatment or surgery or just gender affirming care in general um and it can be in the form of insurance requirements it could be in the form of i'm having to get two separate letters from two different health care providers uh and it's a challenge because it puts us into a position of power and control that can in my opinion negatively impact the therapeutic relationship um and also get in a way of treating the actual issue um so for example i have a lot of folks who come in who need an evaluation who on their depression screens or anxiety screens say i'm perfectly fine i have no issues um zero zero zero zero zero on all the scales um and while that may be true you know part of me wonders is there a motivation to give off a narrative that will make them more likely to get a letter um as opposed to utilizing the opportunity of working on their mental health um if there are issues and some of those restrictions are lifting um so for example the standards of care um it's currently version eight that came out i think a year and a half ago version six that came out in 2001 um had the requirement that in order to start hormones you had to go to therapy for three months minimum prior to getting a letter um now most clinics that offer hormones do a informed consent model that doesn't require therapy uh you know because oftentimes that a the therapy component and also the three months component some folks maybe may benefit from that and it's not to say that mental health treatment is not going to be helpful um but the fact that it's a requirement often gets in the way uh now othering so the concept of othering is you know viewing or treating other people as different or ailing from oneself from the general narrative um and in this dynamic this can apply to a number of different identities people of color women people with disabilities but being left out of the conversation in mainstream america or the cisgender public and it's resulted in a number of different things like exclusionary laws and policies bathroom laws laws restricting gender-affirming care for adolescents not including questions on gender identity and research a lack of training back when i was in medical school i actually had to fight a lot of the administration just to get lgbt topics covered um even to have um my professor list um lgbt identity as a risk factor for suicide um that wasn't listed until i brought up that it wasn't there um and then in that context those who are trans are made to feel less than in the majority population um and then in the context of this there's very few amends made by the majority to um to make up for for a lot of the damage that have been done uh and so this can also translate in the healthcare arena to lack of training um in fact when it comes to the addiction treatment arena you know a lot of rehabs you know have this pattern of advertising that they're lgbt focused or lgbt center to bring people in but when you actually survey them they don't really offer anything that's lgbt specific uh you know in fact one study uh found that only seven percent of those who claimed they had specialized lgbt services actually had a specific service tailored to lgbt populations uh and um and then others had specialized groups that were specifically trained to counselors now when it comes to etiology so while the definitive etiology for gender dysphoria has not been found the best evidence seems to indicate a physiologic causes b psychological causes c hormonal imbalance, or D, chromosomal abnormalities? So I'll give you a minute to think about that. So the answer is A, physiologic causes. Even though the specific causes or etiologies of gender identity have not been solidified, a lot of the data points to physiologic factors. So, but a lot of the research on why people are trans, at least over the past few decades, have focused on trans as a pathology that needed to be treated or cured as opposed to exploring the origin of why some people identify in a particular way. So for example, Robert Stoller in 1968 was a prominent psychoanalyst at the time and he suggested that female to male transgender people had been ugly, non-cuddly babies whose stereotypically feminine and usually depressed mother had not received sufficient psychological support from a masculine but distant father. That's the thing with psychoanalysis, oftentimes the mother is blamed or the parents are blamed. This has been proven to be not true. And then he also wrote in his paper that the trans woman or male to female transsexual who was attracted to men, they had been brought up as an especially cute boy with an overly seductive mother whose excessive bodily contact with child leads to a female gender identity. Ethel Pearson and Alaina Olbesey in the 70s focused more on the developmental model of Margaret Muller and equated gender identity and development with separation individuation anxiety. So for example, like the child's separation individuation with the mother can lead to a fantasy of symbiotic fusion with the mother than a female gender identity. This has also been proven to be false. The 90s brought on a lot of anatomical studies with the advent of different scanning technologies. And they did find a part of the brain that was female sized in trans women compared to cisgender women, specifically the bed nucleus of the striata terminalis but it's not been replicated in future studies. And then in 2005, there was more of a genetic approach. They took infants who were XY chromosomes were raised female for one reason or another, either female eugenicists or ablation. And they found that those folks had a higher rate of those who identified as trans men, which suggested that there may be some genetic component, but it wasn't 100%. I'm gonna skip past this. Yeah. And in addition to pathology gatekeeping, so countertransference also can play a role in a barrier with working with patients. So just to review, so countertransference refers to the therapist's unconscious and sometimes conscious reactions to the patient and to the patient's transference. The transference comes from the patient, countertransference comes from the therapist. And oftentimes these thoughts and feelings are based on the therapist's own psychological needs and conflicts that may be unexpressed or revealed. This is often why therapists are recommended to undergo their own therapy, to work out some of their own issues, but this can come out in the psychotherapeutic element here. And the concept of transphobic countertransference came up in 2017 by a psychoanalyst by the name of Griffin Hansberry. They, in their work with patients, but also doing a review of case reviews from other therapists, analyze the concept of transphobic countertransference and the different components that are related to it. And they wrote specifically about psychotic transphobic countertransference or TCT, which talked about a set of affective differences, distorting reality that any clinician may have in the face of gender difference. Essentially a concept that goes out of reality. It's not in reference to psychosis that one may see in schizophrenia. It's a psychotherapeutic form of psychosis that talks about a delineation from reality. And this can lead to a number of different interactions, for example, emotional dysregulation on the part of a therapist. So for example, some case studies show that therapists when working with trans patients recounted a vague but constant distress sensation of being uncomfortable or incomprehensive, almost as if working with trans or non-binary folks led to a threat of their own gender identity, leading to feelings of going crazy in response to conceding to believe in trans identities or even using pronouns. This can also lead to a fixation on a cause, a trans identity, why are you trans, as opposed to working with a person as a person, focusing on the etiology of things or associating gender confirmation surgery with mutilating the body or just having someone's need to talk about gender expressions or explore the gender as overly problematic. In a recent chapter on transphobic countertransference, Tobias Wiggins talked about two other types of TCTs that could come out in the interaction, including perverse TCTs. The perverse defense is essentially using a special object to help ignore an upsetting reality, kind of like a security blanket. And so those with perverse transphobic countertransference sometimes use concrete concepts to investigate and describe concepts that are much harder to conceptualize in reality. So for example, the DSM, they have criteria for gender dysphoria and oftentimes stick to that. And the patients who are trans don't fit that narrative to a T, that they're not trans enough, they're not getting their procedure or their support. And this also can manifest to as just passive failure to educate oneself. Sometimes there's a guilt involved with this. And so just avoiding the educational component can resolve the anxiety of the guilt that falls under the category of perverse TCT. Neurotic TCT has been most recently developed when I think of all the three, probably the most common and also potentially the most helpful. Let's keep in mind kind of transference isn't necessarily bad. In fact, it could actually be therapeutically helpful based on your interaction with the patient. And just as a review, so Freud termed neurosis as a creative expression of an unresolved psychological conflict. So in this context, sometimes the neurotic version of TCT can come from the therapist own personal experiences with gender, whether it was troublesome or not. And so, so this can look like the periacutic delay of access to hormonal surgery or asking appropriate questions or loss of therapeutic attention. And this can be both at a negative and sometimes positive concept. So just for example, because I worked on this myself with some patients that I was seeing. So, my experiences with gender personally are that of gender fluidity, kind of forget the binary, people should present how they want to and that's fine. But when I encountered a few patients who wanted to fit in that binary, who wanted to blend in, who wanted to so-called like blend with the general public, I had a little bit of a kind of transferential reaction to that. You know, like why is it important that your hair and your makeup look a certain way in order for you to be trans enough? Let's talk about this, as opposed to hearing that person's perspective and where they're coming from on that. This comes from a place of wanting safety or just that's just what they want. And ways to work on this, particularly with the neurotic kind of transference is really just working on one's own experiences with gender, with self-reflection, self-analysis. This is where one can also think about their own experience of the gender, because we all have experience of the gender and not just trans folks. In terms of best practices, so first and foremost, building rapport is very, very important to me when I talk to patients and when I establish a connection. And I am very mindful of the fact that there is a lot of baggage that happens decades before the encounter when it comes to what psychiatrists have done, what other healthcare providers have done. And so when working with patients, I try to give sometimes a disclosure when it comes to that. So for example, when I get evaluation requests for patients who are seeking letters for surgery, I often start off by saying, look, I'm not trying to assess whether you're trans enough to get the letter. You wouldn't be here otherwise. But my purpose here in writing the letter is to help you get the best results and the best success in your procedure. Not to be a gatekeeper to say whether you're getting the surgery or not, but more how can we improve and maximize your success here? And that often lowers the anxiety level. Other goals that pop up, so addressing difficulties with self-definition, sometimes gender-related, sometimes not gender-related. So for example, I worked with a patient who is white, assigned female, sex at birth, and has been thinking a lot about taking masculinizing hormones. And has kind of lived in a body that's where they're either androgynous and we're very involved with the queer community locally, but struggle with the concept of doing a full transition to being a binary trans male out of concern that I will appear to be a white male, someone who is a person with that, how would I feel about that? They didn't know how to talk about it or how to feel about that. So as we talked about that element of self-definition and the notion that identity on the surface is one thing, internalized identity is another, and actually referred that person to a therapist in the area who is also a white trans male to talk about those issues together with identity. Coping with the impact of stigma that come out. Sometimes they come out before the encounter, sometimes as they transition, they experience stigmatization in ways that they may have been expecting or not expecting. So for example, with a lot of the women that I've worked with who are in the process of coming out and presenting as women in the outside, often come back to me and say, there's this experience of like the male gaze for the first time, the males are looking at me as a woman. And in some cases in a way that's pleasurable and that like it's good to get attention, but also uncomfortable that why are all those people staring at me? Now, other things to include the right expression, developing one's own style, and that can take a lot of time and also a lot of thought and effort. I referred folks out to makeup consultations. There's also a website called strandsfortrans.com. That's actually a database of hairstylists that are affirmed to be trans friendly because sometimes just figuring out how to wear your hair in a way that can make you feel most comfortable and affirmed can be very challenging. And a lot of hairstylists may not understand or maybe discriminatory in some form or fashion. And then also deciding other things like hormone surgery, not every trans person wants hormones, not every trans person wants surgery. And so sometimes evaluating whether it's something that they want or not takes a lot of time. And we talk about that quite a bit. Finding social support, also very, very important. So I live in upstate New York. And so while there is a decent number of trans individuals that I work with, there are very few social support resources. There's one group that meets once a month on Zoom that have maybe two or three people. I tried to connect with my patients to that group and it turned out to be a lifesaver to just talk to other trans people for the first time. And to discuss some of the complex issues that even though her family was very supportive, just didn't really understand or had difficulty trying to understand. And then helping family members and specific families is also very important too. In fact, especially when it comes to adolescents and parents, there used to be here a support group for parents of trans adolescents that helped address some issues specific to parents, particularly things like coping, mourning with a loss of who they thought their child was and embracing who their child is now. And sometimes it's helpful for parents to talk about that in the group without the adolescents present. When it comes to substance use treatment in particular, so a lot of the experiences on the outside world can also impact one's relation to their recovery and their addiction, including cultural victimization, transphobia. A lot of these can lead to bad feelings that lead to, I need to treat these bad feelings with drugs and then leading to relapse or steering away from sobriety. So oftentimes focusing in those elements have been very key at keeping people sober and keeping people comfortable with who they are. It's also important when building resilience in patients as well. Community is super important in my opinion when it comes to resilience. And while some areas may be lacking in terms of in-person supports, there are quite a few resources online, Facebook groups, Reddit groups, and also 12-step groups, in my opinion, have been very helpful as well. 12-step groups like Alcoholics Anonymous, Narcotics Anonymous, they're free, they're available in most places. There are groups that are LGBT and they do work at helping people stay sober. A lot of folks get nervous about 12-step groups, typically in conservative areas because they worry understandably that what if I encounter transphobia or someone who doesn't understand me or say disparaging things? And while it's fair, one of the things I always try to remind folks who are considering 12-step groups is that they're tradition. So the Alcoholics Anonymous and other fellowships have the 12-step, but there's also the 12 traditions, which is more of a kind of a guideline for how groups are run. And the tradition basically says the only requirement for a membership is the desire to stop drinking or using. So it doesn't matter who you are, it doesn't matter what you did, as long as you wanna stay clean or stay sober, you're welcome and no one can kick you out. So oftentimes talking about that leads to some elements of comfort and understanding that I do belong here. And in my experience, oftentimes in groups like these 12-step groups, the camaraderie of people who are struggling with recovery, struggling with stopping use, finding, discovering a life in sobriety often supersedes that of gender, race, socioeconomic status, just because that connection of people in recovery together is what some people would say is what 12-step groups are all about. Now, some particular therapies have also been developed over the years that focus particularly on transgender individuals, both when it comes to coping with stress and discrimination or assisting with the developmental process when it comes to developing gender identity or deciding one's own transition process. Solution-focused therapy is one of them that focuses more on a brief type of encounter that focuses on strength. These are basically tuning them up so they can go out into the world and have skills that are helpful for them. DBT as well, dialectical behavioral therapy, it's not trans-specific, but has a number of different skills that can be helpful at helping patients manage things like anxiety or uncomfortable emotions that can come with discrimination and abuse. And then there is a version of CBT that have come out about 10 years ago called transgender-affirming CBT. It grew out of gay-affirming CBT, and it focuses on, it has a general CBT format for something like depression or anxiety, but it includes specific psychoeducation on coping with transphobia and dealing with uncomfortable feelings that can come from that. So this is actually a sample schedule for transgender-affirming CBT, and it can include things that are in all sessions for CBT, like how thoughts affect feelings, things like that, but also include particular information on examining stress, minority stress, and how that impacts depression or how that impacts how you're feeling, examining transphobia at an individual, institutional, cultural level, and how that impacts you, or identifying how transphobia affects thoughts, feelings, or behaviors, and how you can work towards building coping skills from that. So this is eight sessions, but I imagine it could be shifted and changed based on where you're looking. And then finally, I'm gonna talk about cisgender privilege. So when it comes to privilege, a lot of people think about white privilege or male privilege. It's also cisgender privilege as well. And the concept of privilege is essentially the notion that one gets benefits in society based on a certain identity that they have. And oftentimes, part of a privilege is not realizing, recognizing that you have it. This quote is from Peggy McIntosh, who did a lot of writing in the 80s on white privilege. And she's white herself and wrote that, "'My schooling gave me no training "'in seeing myself as an oppressor, "'as an unfairly advantaged person "'or a participant in a damaged culture. "'I was taught to see myself as an individual "'whose moral state depended "'on her individual moral will.'" Implying that oftentimes, just the notion of having privilege, not recognizing it may make you falsely believe that I did a lot of this on my own, regardless of my own identity, or if you just pull yourself up by your bootstraps, then you should be okay. It doesn't matter about the politics for all people, right? But that's the element of privilege that can be involved here. So some examples of this, using restrooms without fear of abuse. Your gender is an optional forms. I mean, you can go on and on about this, and you can see, you can Google examples of white privilege examples of male privilege all around. But the point is, is to recognize one's role in this, and also important when it comes to addressing what your patients may be going through. And then finally, I'd be remiss to not talk about how the community itself can improve in a number of ways. So for instance, I mentioned earlier that a lot of social events take place in bars or places that serve alcohol, but there have been a growing trend of community events being sober friendly, like bars having zero-proof nights. Like there's one in Syracuse that has a zero-proof night where all they serve are mocktails that are specialized creations by the bartender, or in certain settings, offering alcohol-free mouthwash or hand sanitizer, or not having alcoholic drink options, or having alcoholic drink options. And then also people recognize their own implicit biases when it comes to sobriety and recovery. Sometimes when the community offers support, there could be a challenge when it comes to addiction, beer, how do I address or talk to this person? And that could be addressed from a community level. But I think I'll stop here. There is a section on medication treatment, but I think I'll hold off on that to make room for questions. Thank you so much for that excellent presentation. While we're waiting for questions to come in, and just to remind people, you can put them into the chat box or also the Q&A box. So I'll start off with a question of my own. I've recently had a couple of people who recognize their transgender identity much later in life. Have you noticed any differences in this population, or do you have any pearls on how to kind of interact with this group? Yeah, so yes, when I worked at the VA, this is what I encountered quite a bit. Those who were later in life, and by later in life, 50 plus, sometimes 60 plus coming out as trans. The narrative that I often hear though is that they realize that they were trans when they were later in life, but more they had that realization all along, but either they denied it or covered it up, or did whatever they can to suppress it. And then the suppression gets to a point where this can't handle it anymore, can't tolerate it anymore. The narratives can also change a little bit too. So for instance, there are a lot of case reports of those who are older, who chose not to transition until after the partner passed to minimize conflict or waited until after retirement to minimize workplace discrimination. And having those be particular goals of transition more so than how one particularly appears or the effects of hormones. So sometimes those viewpoints could be a little different as well. Looks like Regan has a hand up. I'll try to allow you to talk, Regan. Hi, Regan. Hi. Can you hear me okay? Yeah, I can hear you. Hi. Hi. So before I ask my question, I want to mention that I work as a therapist. I'm sure many of the people who have come today do. And I found your presentation very helpful, and I want to thank you for that. In my work, I am very passionate about working with LGBT plus relations, and I found that I have a lot of trans men who I see as clients. I don't know why in particular trans men, but all are welcome, and it's great working with them. I have noticed occasionally, though, there will be instances of internalized prejudice. And I think that if you don't mind talking about a little bit like some different ways in which like maybe strategies for dealing with internalized prejudice, particularly for the trans community, that could be really helpful. Yeah, and so by prejudice, just to make sure I understand where you're coming from, you mean like internalized transphobia, that kind of prejudice or prejudice and other? Yes, sorry. Yeah, so like, for example, I've had clients say like things along the lines of like, maybe I'm trans because of this assault or things like that. And those things are, you know, they're easy to challenge with facts and research and things along those lines. But I think it would also be helpful just to hear a little bit from your perspective, if you have advice for a therapist who would be addressing something like that. That's an excellent question. And thank you for asking that. And thank you for your work in the community. And I have encountered this as well in a number of different contexts, ranging from, you know, if I don't appear a certain way, then I'm fake, or if I present a certain way, then I'm bad. I think I'm going to talk about two different concepts. I tend to take a more cyclodynamic approach or like a dynamic approach when working with patients on a therapeutic level, if I'm not doing medication management. And so oftentimes when that comes up, I ask them to explain what they mean by that and explore it, then like, where is this coming from? Now, shifting this to a CBT perspective, I'm just going to change the slide here. This is where a lot of the concepts from this gender affirming behavioral therapy comes from. And I like a lot of these because what it does is it takes the facts like what you're saying and applies it to why this is coming from that place and why it may not necessarily be factual. And the fact that thoughts are not necessarily facts, you know, so let's explore where this is coming from, you know, so I'm all about insight, building insight into why people are thinking the way that they do, whether it's positive, negative, healthy, or not healthy. Hope that answers your question. Yeah, that helps a lot. Thank you so much. Sure. Dr. Stifler, I think you're muted. Oh, sorry. A question you mentioned about the role of doing the evaluations for, I guess, gender affirming surgery or hormonal treatment. And I understand setting the frame of trying to have the patient not kind of like exclusively or predominantly viewing you as the gatekeeper, but I mean, you are the gatekeeper, right? So yeah, I'm just wondering, I know I'm kind of like laser focusing on what might be like the hardest part of doing a lot of the work that you do. I'm just wondering, because I feel like that's the thing that I, with my much more limited experience working with this population, I kind of like fail to know enough about how to talk with them about exactly how the thought process would work. So I'm just curious if you have any good examples of maybe when you had to make the decision that the person like really didn't want you to make and how you kind of explain that to that person. Yeah. And so that's a really great question. And I think it comes from in terms of how I approach things. So what I typically say at the beginning, like I mentioned, is I'm here to support you and getting the best results possible. And when it comes to gatekeeping, there can be different reasons to be a gatekeeper. So oftentimes, especially in the old days, there's this question of, are you trans enough to get the procedure? Can we guarantee that you are trans enough to where you can get this irreversible surgery and actually like it? But if you don't appear trans enough to me, if you don't appear feminine enough to me, then I don't think you're trans enough to not get into surgery. That dynamic comes from years of old outdated guidelines that required things like a lived in experience before starting hormones or long periods of therapy. And so the letter writing recommendation has shifted in terms of its utility. However, that gatekeeping element of, are you trans enough or not, kind of still sticks in the psyche of a lot of people who access mental and physical health care. So by shifting the framework of like, yeah, I am kind of a gatekeeper here, but it's really more for the purpose of ensuring the best results for you from a mental health standpoint. Some cases where I have had some reservations writing a letter don't involve like, are they trans enough or not, but A, are they able to consent to surgery, because that's another component to letter writing. Do they have a disability that keeps them from providing informed consent, or are there barriers in the way to success? And then also untreated illnesses, you know, so untreated depression, active substance use. So oftentimes, I approach it from that realm of, let's address this first. You know, yes, it can be perceived as a barrier, but this is helping you overall. I also try to frame it from a sense of, you know, you're not getting the letter, but more, let's work on this first, and then I feel comfortable signing off on helping you get the procedure that you need. So it's not a, you know, I'm just saying no to you, but more, let's help you in a particular way. I hope to get a certain treatment that'll be helpful for you to help keep you healthy through the process. But it is tough, you know, and I think when it comes to a lot of the guidelines, even as guidelines become more, become updated and become less gatekeeper-y, it does put us in a position as a gatekeeper, and that could be a challenge. And some of it is there for a reason. You know, the element of talking about gatekeeping isn't to say patients should get everything that they ask for, because sometimes there are barriers that are placed for a reason, you know, medical barriers or psychological barriers, but that's part of the dynamic that pops up when you're working with a patient in the room. It's remarkable the degree of suffering that many of the trans population goes through, and the data that you presented is chilling, right? You know, like a 14 times greater likelihood of attempting suicide, and essentially 40% of the time they're in psychological distress. Is there data to support that once they engage in treatment and have hormonal therapy or gender-affirming surgeries, that those numbers improve? So yes. And so there have been longitudinal studies that suggest that as one accesses gender-affirming treatment, whether it be hormones or sometimes surgery, or really just affirmation that quality of life improves, rates of depression drop. And I've also seen this from a clinical standpoint as well. Patients who are chronically suicidal, were listless in life, couldn't leave the house, once they got access to their first shot of hormones, became, you know, much better. The suicidality went away, the depression became much easier to manage. It's like a night and day difference. Yeah, any other questions? I have a feeling that maybe the Q&A box is not working. Yeah, because I see it's not open. I mean, we have a little time. I can ask another one. I wonder if any, I don't know if there's data on this, or again, with your experience about how important it is with the therapist, I guess, whether it's gender identity or sexual orientation or the gender expression, right? I mean, I'm very aware I'm like a cis white guy as soon as somebody walks in the room, and I dress that way too. And that being said, I mean, I am considering myself more well-trained than probably many, you know, especially after attending a talk like this. So I've kind of like, you know, I thought it was appropriate self-reflection to kind of doubt if I'm the right person, at least superficially for whoever's walking in. But then I realized if I go into this room doubting myself, it's going to come across in the alliance and like, that's probably not going to make them feel good either. So I just try to go into it with appropriate levels of self-awareness and confidence, and that has seemed to be helpful. But I also don't know if, you know, again, it's a very small end. So I don't know in your experience how, if you're giving referrals, for example, like how much are you putting in, how much are you kind of reinforcing with a patient who might think that that's a characteristic that should be more important than like, you know, location or cost or something like that. Yeah. Yeah. And so in the Syracuse area, there's actually a resource that's, that was generated and updated on a regular basis of healthcare providers, therapists, that actual trans people have seen these clinicians put together in the list. And, you know, oftentimes when I ask some of these folks, like, what do you, like, what criteria do you think about when, you know, saying that someone is gender affirming and enough to refer to other folks who are trans? And, you know, general sense is a general awareness, but also an ability to be open, you know, and that in itself is, it's important, you know, so when it comes to, because you mentioned like having an awareness and confidence, and that is really important, I agree with you. But I think there's also a, there has to be a comfortable, a comfortability with making mistakes, you know, so I may have gotten your pronouns wrong, or I, maybe I use this term, but let's use this term instead, you know, and that actually leads to a clinical pearl that has helped me and will hopefully help other people in this presentation. But when you make a mistake, one thing that I see a lot of people do, let's say when they get a pronoun wrong, they're like, oh, I'm so sorry. I beat the big man, I'll never make it again. You know, when that happens, they make it about them. So oftentimes, when you make a mistake to say thank you, you know, thank you, I'll use and then use the correct pronoun after that, as you learn what it is. But being open to learning a different experiences, being curious. Yeah, and you bring up a really important point that that also came up in a lot of what I've been reading about counter-transference, is this notion of siloization of trans care, you know, because sometimes there's this fear, you know, well, I don't know trans folks very well, so let's send everything to the general, to the gender specialist. So, you know, so I, you know, that way we can assure they have the best care. And while that's not necessarily a bad thing, I think part of where it becomes a challenge is A, the resources are already limited in all communities. But I think it also cheats the clinician out of an opportunity to become a richer clinician. So, I mean, we work as psychiatrists and therapists with a number of different populations, a diversity of people. But, you know, this particular population gets singled out for X, Y, Z reason, you know, and for some reason, I understand, for some reasons not, but that could be a bit of a challenge. Thank you. Looks like we might have time for one more. Hillary, you're unmuted. Hi, I have a sort of related question. It's about testosterone supplementation. And so I'm seeing a lot of veterans who are CIS and requesting, who have some form of hypogonadism, usually as a side effect of methadone or buprenorphine, and are on testosterone supplementation. And I have this sense both like anecdotally, and it seems like it's affecting how they see themselves and like how they feel. And I'm having trouble like incorporating that into my formulation of them. And I was curious if you could talk about testosterone supplementation in CIS men as well, and things to keep in mind when treating this common side effect. Yeah, that's a great question. And I actually see that a lot in my practice as well, because the Palmore Treatment Centers is mainly a methadone clinic. So I do encounter many CIS men who after years and years of methadone have this low testosterone. And it is accompanied with what you were mentioning, feelings of depression, low self-worth, trouble feeling like a man in some ways. And then it's not until the testing for testosterone is done, because sometimes it's not even picked up on until months or years down the line, does this concept of testosterone supplementation come up as a potential to help us get to a level where they were at before, because testosterone helps with energy levels, mood. When it comes to self-conceptualization, where I see a lot of trouble is where the person can't take testosterone one reason or another. So for instance, there's a medical complication involved with it, or they get a symptom like phantom mastia that would not be desired, or rage, or anything along those lines that can take something away that they know has been helpful for them. And so part of the coping process is dealing with that. I also see a lot of kind of self-conceptual issues among those who actually use anabolic steroids in a non-healthcare monitored manner. Essentially, using higher levels of testosterone either in a cycling manner for a bodybuilding. And that often comes with its own level of self-identity issues when it comes to size and feeling strong and tough. Oftentimes they come from backgrounds where they did not have that feeling. They felt little or belittled, or there is abuse at the home. So they try to fight against that by making themselves appear bigger and work out. And that often can be correlated with substance, with methadone and opioid use, because when you work out a lot, you get a lot of pain, you take opioids to help with the pain for working out, and then that cycle continues. So that's something that I see quite a bit as well, assuming their heart can, will keep them living. That's really, those are helpful considerations to keep in mind when I am navigating all of the complexities of this patient population. Thank you. Absolutely. Yes, it's tough. And I think it's great that it's coming out more because when people are often started on methadone, the concept of lower testosterone levels doesn't always come up just because it's something that happens far down the line. And so sometimes when it happens, it comes as a shock. Like methadone has been doing this entire time among all the other things it's doing. I already can't go to the bathroom, I have this problem too. So there's a set element. All right, well, that brings us right to our finish time. So thanks for the very thorough and enlightening talk, Dr. Johnson. So we appreciate it and look forward to seeing everybody in June. Thank you so much. This is great. Okay, bye. I appreciate being here.

Advanced Addiction Psychotherapy

Transgender Patients

Evidence-based Training

Addiction Psychiatry

Substance Use Disorders

Social Factors

Gender Dysphoria

Co-occurring Mental Health Issues

Barriers to Care

Culturally Competent Care

Gender-affirming Therapy

Mental Health Outcomes