Daphna Stroumsa1,2, Leah A Minadeo3, Mariam Maksutova4, Molly B Moravek1, Rob Stephenson5,6, Paul N Pfeiffer2,7, Justine P Wu2,8. 1. Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, United States of America. 2. Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, United States of America. 3. School of Information Sciences, Wayne State University, Detroit, Michigan, United States of America. 4. Medical School, University of Michigan, Ann Arbor, MI, United States of America. 5. Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan, United States of America. 6. The Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, Michigan, United States of America. 7. Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, United States of America. 8. Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States of America.
Abstract
OBJECTIVE: Gender-affirming hormones (GAH)-the use of sex hormones to induce desired secondary sex characteristics in transgender individuals-is vital healthcare for many transgender people. Among prescribers of GAH, there is debate regarding the value of a universal requirement for an evaluation by a mental health provider prior to GAH initiation. The purpose of this qualitative study was to describe the range of attitudes and approaches to mental health evaluation among GAH providers in the United States. We analyzed the providers' attitudes and base our recommendations on this analysis. METHODS: We conducted semi-structured interviews with 18 healthcare providers who prescribe GAH across the United States. Participants were purposefully recruited using professional networks and snowball sampling to include those who require mental health evaluation and those who do not. We adapted domains from the Theoretical Domains Framework-a framework for understanding influences on health professional behavior-to inform the interviews and analysis. Guided by these domains, we iteratively coded text and identified theoretical relationships among the categories. RESULTS: While some felt a universal requirement for mental health "clearance" was necessary for the identification of appropriate candidates for GAH, others described this requirement as a form of "gatekeeping" that limits access to care. Themes we identified included providers' ability to ascertain gender identity; concern about mental illness; GAH provider and mental health provider expertise; and provider roles. All providers appreciated the potential advantages of mental health support during GAH treatment. CONCLUSION: Providers in our study practice on a continuum of care rather than adhering to strict rules about the requirement for mental health evaluation prior to GAH treatment. Where they fall on this continuum is influenced primarily by their perceptions of transgender identity and transition, and their interpretation of risk for significant mental illness and its association with transness. Providers who required universal evaluation by a mental health professional tended to hold essentialist, medicalized, and binary ideas of gender and transness.
OBJECTIVE: Gender-affirming hormones (GAH)-the use of sex hormones to induce desired secondary sex characteristics in transgender individuals-is vital healthcare for many transgender people. Among prescribers of GAH, there is debate regarding the value of a universal requirement for an evaluation by a mental health provider prior to GAH initiation. The purpose of this qualitative study was to describe the range of attitudes and approaches to mental health evaluation among GAH providers in the United States. We analyzed the providers' attitudes and base our recommendations on this analysis. METHODS: We conducted semi-structured interviews with 18 healthcare providers who prescribe GAH across the United States. Participants were purposefully recruited using professional networks and snowball sampling to include those who require mental health evaluation and those who do not. We adapted domains from the Theoretical Domains Framework-a framework for understanding influences on health professional behavior-to inform the interviews and analysis. Guided by these domains, we iteratively coded text and identified theoretical relationships among the categories. RESULTS: While some felt a universal requirement for mental health "clearance" was necessary for the identification of appropriate candidates for GAH, others described this requirement as a form of "gatekeeping" that limits access to care. Themes we identified included providers' ability to ascertain gender identity; concern about mental illness; GAH provider and mental health provider expertise; and provider roles. All providers appreciated the potential advantages of mental health support during GAH treatment. CONCLUSION: Providers in our study practice on a continuum of care rather than adhering to strict rules about the requirement for mental health evaluation prior to GAH treatment. Where they fall on this continuum is influenced primarily by their perceptions of transgender identity and transition, and their interpretation of risk for significant mental illness and its association with transness. Providers who required universal evaluation by a mental health professional tended to hold essentialist, medicalized, and binary ideas of gender and transness.
Authors: Annelou L C de Vries; Jenifer K McGuire; Thomas D Steensma; Eva C F Wagenaar; Theo A H Doreleijers; Peggy T Cohen-Kettenis Journal: Pediatrics Date: 2014-09-08 Impact factor: 7.124
Authors: Daphna Stroumsa; Deirdre A Shires; Caroline R Richardson; Kim D Jaffee; Michael R Woodford Journal: Med Educ Date: 2019-01-21 Impact factor: 6.251