Transgender Mental Health Care on the Transition Pathway

By Susan Gallagher

In honor of LGBTQ+ Pride Month, we talked with three experts in the Department of Psychiatry & Behavioral Sciences to learn more about how they support gender diverse patients at Duke. Meet our experts:

Amber Graham, MD (she/her) recently graduated from the Duke Psychiatry Residency program and will be joining the Department of Psychiatry & Behavioral Sciences faculty this fall. In her final year of residency, she participated in the resident-run transgender clinic elective. As a faculty member, she plans to provide psychiatric care to hospitalized medical and surgical patients, manage emergencies in the behavioral health emergency department, and continue her outpatient work with a focus on providing care to transgender patients and their families. 

Leigh Spivey-Rita, PhD (she/her), a clinical associate, spends much of her time providing outpatient therapy with transgender and gender-diverse children and teens and working with their parents. She also works with the adult psychiatry triage team, supervises trainees in the Family Studies Clinic and provides testing in the Pediatric Neuropsychology Clinic.    

Dane Whicker, PhD (he/him) is a medical instructor and the Director of Gender and Sexual Diversity for the School of Medicine. He works primarily with LGBTQ+ patients and their families, with a focus on helping people who identify as transgender or non-binary navigate their medical transition. He also provides support and therapy to LGBTQ+ patients around issues such as sexuality, dating, coming out and coping with discrimination.

Below are some key excerpts from our conversation, edited for length.

What are some of the mental health challenges transgender children, adolescents and young adults face?

Amber Graham, MD: Transgender folks often face similar mental health difficulties that cisgender folks face, and often I see my role as providing high quality care for these issues while providing a deep level of validation for their gender. However, these difficulties often come up more frequently in the trans population as a result of living in an environment that invalidates their innermost self on a daily basis. Particularly noteworthy among trans youth is a fear of rejection and of not being accepted by their families. It’s so important to work with families on acceptance of their trans family member, as this is a factor significantly associated with poor mental health outcomes.

Leigh Spivey-Rita, PhD: This population can benefit from receiving support related to their identity. Youth come to an awareness of their gender identity at different points. Depending on when that happens, there may be more or less stress associated with coming to terms with their identity, whether that’s fears about being rejected by their family or friends if they were to come out, or on a practical level, not knowing how to tell other people about their identity or how to start transitioning their gender expression to be more congruent with their identity. 

In terms of mental health, gender diversity is stigmatized in our society. And because of that, this population can experience chronic stress associated with those experiences—like harassment related to their identity or structural stigma, such as their school not having appropriate bathrooms to support all students. These chronic stressors can lead to things like anxiety, depression and suicidal thoughts and behaviors.

Dane Whicker, PhD: A lot of the mental health challenges stem from discrimination or anticipated discrimination. They've seen LGBTQ+ people get bullied on TV and friends getting bullied at school, or they’ve been bullied themselves. This creates a chronic anxiety about being hurt, and often they're too embarrassed or ashamed to tell a parent, teacher or leader who could help them. 

We often see transgender children and teens holding so much shame and anxiety that it becomes difficult to learn—they’re distracted in school, they’re coping by doodling during class, their grades go down. These are often signs that someone’s really dealing with something. And depression, self-harm and thoughts of suicide are not uncommon. 

In what ways can social and/or physical transitioning help transgender youth/young adults thrive?

Graham: Having access to resources to support medical transition is dramatically helpful for trans youth.  For those who do pursue these resources, aligning physical characteristics with their gender allows them to feel seen by others and experience less discrimination, and lets them see themselves more fully. It also leads to less misgendering by others, reducing the chronic stress associated with social intereactions, which frees them to be able to engage more completely in their lives.

Spivey-Rita: There are so many ways that becoming our authentic self helps us to thrive. Whether it’s about our gender identity or some other aspect of who we are, being forced to hide part of who we are creates all kinds of stress and unnecessary burden. 

If youth can feel truly themselves and express their true selves to the world, that allows them to put more of their energy into their peers and their social interactions. And they can really show up in school and pay attention in class and learn and contribute with their full selves, without being preoccupied with other aspects of their lives.

Whicker: Once we’ve figured out that a person identifies as transgender and they begin making changes, their mental well-being tends to improve. There’s more comfort when they hear themselves called by “ma’am” or “sir” or the right pronoun without any prompting—it feels like a victory. It’s like a new world has been opened up for them, and they can really be who they are.
That’s one of my favorite things about what I do—just seeing kids who were depressed or anxious become happier. There’s just a sense of peace and calm that comes with being treated the way that you feel like you should be treated because that’s who you are.

What are some of the ways providers at Duke support the well-being of transgender youth/young adults?

Graham: A lot of it is listening and being open and non-judgmental, and giving our transgender patients the floor to share what’s coming up for them. As providers, we need to notice what sorts of biases we might be bringing to the table and try to leave all of those at the door. Our goal is to sit with the person in a place of searching and help them figure out what makes sense for them, which may or may not be medical treatment or surgery. And if it is, then we help them navigate that. We support them by writing the required letters, guiding them through the process, talking with their parents and troubleshooting as needed.  

Spivey-Rita: Something that Duke does really well is that we focus on whole health care for gender diverse patients. We’ve got a fantastic multidisciplinary team that spans all aspects of trans health care. Our network of providers communicate with each other on a regular basis, so we can coordinate care to meet the unique needs of this population and to make sure that their experience in the health system is positive and affirming.

We’ve got Endocrinology to support transition for folks, and we’ve got outpatient therapy and medication management services for any psychiatric concerns they may have. We can also help them access voice coaching to help their voice sound more congruent with their identity, and we can help them get connected to dermatology services if their body changes associated with their gender-affirming hormones are leading to increased acne. All of these different aspects of care, and a few others, improve the overall quality of life for youth going through this unique experience of becoming their authentic selves. 

Whicker: One of the things I do a lot is talk with parents about their child’s transition process. Engaing parents from the beginning is vital. For example, when we work with Pediatric Endocrinology to pause puberty, we talk about the fact that we have early bloomers and late bloomers and some who are right on schedule. By pausing puberty, which is considered a "fully reversible intervention," we are intentionally inducing a late-blooming puberty to allow for enough time and work in therapy to make sure that the child goes through the right puberty—the puberty they're not going to regret later, one that won't cause years of pain, hiding and emotional distress. 

One thing that really seems important for parents to understand is that allowing a trans child to go through the puberty dictated by their pituitary glands is not a neutral option. In fact, it's the least affirming option. Puberty suppression is our "middle ground." It is the puberty route that has the best chance to avoid major surgery like a double mastectomy later in life or the formation of a skeletal structure that even the most talented plastic surgeon can't fully undo. I believe most parents want their children to be happy and live their best lives. As providers, it's our job to do the best we can to help parents realize how to do that for their children. 

What advice do you have for youth and young adults who are just beginning to explore their gender?

Graham: No two trans people have the same experience. It can be tempting to try to fit yourself into a box the way society tries to fit you into a box. You might feel you have to come out in a particular way, or you have to do things in a certain order—but in reality, it doesn’t have to be any particular path. Do what feels right for you when it feels right for you. Your journey is your own.
It can be really hard for trans people to talk to about their feelings to others, and the online world offers connection anonymously. These connections can be very helpful, but frequently comparing your experience to that of others can lead to suffering. My advice is to ask yourself, “Is this interaction or post that I’m reading helping me feel better and helping me move forward, or is it hurting me and making me feel more confused, upset or angry?” Decrease the behaviors that pull you down and increase the ones that bring you joy.

Spivey-Rita: Exploring your gender can be a really exciting period of time as you’re getting to know yourself on a deep level. For some folks, though, that can also be a really lonely process. There can be a lot of fear about how people around you might respond or react. I would encourage you to think about how can you reach out for support and connection as you’re going through this really exciting and potentially scary process of coming to terms with who you are and being able to share that with the world. So whether that’s getting support from your friends, your family or a therapist, having this support can make the process a lot easier and help you focus more on the fun, exciting aspects of the identity exploration rather than the scary parts.

Whicker: Try not to self-monitor. A lot of times, transgender youth will not give the full story, especially if they’re afraid their parents will reject them if they say what they’re really experiencing—and that just leads to more confusion. My advice is, to the extent possible, live your truth and speak your truth. And find someone you can trust—try to seek out a trusted adult whom you know will support you. Think of it as having a “floatie,” someone that’s going to keep you up as you start coming out.

What are your top go-to resources for transgender youth and/or young adults?

Graham: Finding a gender-affirming therapist or psychiatrist can be extremely helpful in moving transgender youth toward their goals. Connecting with other trans folk is also so important in reducing any internalized shame and stigma. Local LGBTQ centers such as the LGBTQ Center of Durham and Raleigh can often be good places to find these connections. The Trans Lifeline (877-565-8860) provides in the moment support by and for trans people, and InsideOut 180 provides support for LGBTQ youth in the Triangle area.

Spivey-Rita: I often encourage parents to watch the documentary “Gender Revolution” to increase their literacy around gender and gender diversity. It can be a nice conversation starter for families.

Whicker: Luna is a great young adult novel that teens really seem to relate to. I would also recommend the Gender Quest Workbook as a resource that can help teens and young adults think through some really important topics and issues related to gender identity exploration. And if they choose to share it with their parents, it can help parents better understand what their child is thinking and experiencing as they explore their gender.