Trans Affirming Psychiatry: We’ve Got Some Work to Do

May 06, 2024

I love practicing psychiatry. It’s a fascinating and humbling puzzle to solve: humans are
endlessly complex, and psychotropic medications—these little molecules that treat everything
from mild anxiety to severe psychosis—are blunt, imperfect, and sometimes life-changing. I’ll
never be bored by the challenge it poses every day. But an even more important challenge it
presents involves the endless potential for human error, bias, and subjectivity. Our internalized
biases and fundamental human flaws can make us extensions of an oppressive culture, causing
harm to patients. So let’s explore its manifestations with regard to gender diversity, and talk a bit
about what trans-affirming psychiatry should look like today.

It doesn’t take too deep a look into the annals of history to see how psychiatry has pathologized
LGBTQ+ communities, in addition to many other minoritized groups. Psychiatry has historically
been used to enforce cultural and social norms, a practice evident from the Victorian Era's
systematic labeling of gender and sexual "deviance" to the classification of homosexuality as a
disorder in the DSM until 1973. Even today, similar challenges persist with the medicalization of
transgender identities and restrictive mental health practices that gatekeep access to care.
To be fair, psychiatry can’t be blamed for the entirety of the problem. Any professional field
operates within a culture, and psychiatry is no different. However, psychiatry is unique in one
important way— it holds the dubious position of acting as an authority on whether certain
behaviors are valid or pathological. By doing this, psychiatry can hinder cultural progress and
slow the achievement of equity on important issues by labeling identity characteristics or
unconventional behaviors as pathological.

The legacy of pathologizing queerness has left a residue of understandable distrust and
skepticism towards psychiatric professionals. It’s critical that we hold space for that in the clinical
relationship, respecting the adaptive nature of a patient’s wariness or hypervigilance. That
behavior makes sense when you understand the deep context for it, and in these communities,
there’s quite a lot! Trans-affirming psychiatric practice therefore involves not just clinical
competencies and basic cultural humility, but also a deep recognition of the historical and
systemic barriers that have shaped patient care, and our field as a whole. Let’s discuss a few
ways we can work against this grain and provide better care to our trans patients.

Principles of Affirming Psychiatric Care

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

  1. Respect for the Patient’s Autonomy and Knowledge: Patients are experts in their
    own lives. An affirming practitioner acknowledges this expertise, viewing the therapeutic
    relationship as a collaboration rather than a hierarchy. Patients always have the option to get their care outside the medical system, and often do just that when we aren’t
  2. Responsiveness to Change and Individual Needs: Medical and psychiatric
    communities are slow to adapt to societal changes. Affirming care requires practitioners
    to stay informed and responsive to the evolving understandings of gender diversity, and
    know that our patients are more up to date than the research will be. We need to listen
    closely to our patients.
  3. Consciousness of Biases: Every practitioner has biases; what matters is the
    awareness and management of these biases to prevent them from influencing clinical
    judgment. Self-reflect, read, listen, and consult with others.
  4. Cultural Competence: A deep understanding of the nuances of TGD experiences,
    including the implications of hormonal treatments and surgeries in psychiatric care, is
  5. Rigorous Humility: It is essential for us to communicate clearly and humbly, admitting
    when they do not know something and being open to learning from their patients and
    peers. I deem this “rigorous humility” because I believe it is a dedicated practice we must
    devote ourselves to continually.

Moving Forward with Allyship

Embracing a truly trans-affirming approach to psychiatric care requires a foundational shift in
how we perceive and interact with our patients, as well as how we critically analyze our training.
We must question our assumptions, listen more deeply, and act with both compassion and
conviction. Trans-affirming psychiatry, therefore, involves more than just adopting new
terminologies, putting pronouns in the patient demographics, or copy/pasting inclusive policies
from the latest training. It’s a philosophy of care that opts into living in tension between research
evidence and community wisdom, and a practice of rigorous humility that can transform how we
think and act.

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


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