Transition in Gender Dysphoria May Improve Comorbid Psychosis

April 11, 2017

Gender-affirmative (GA) treatment may be safe and effective in patients who have gender dysphoria (GD) with comorbid psychotic disorders, early research suggests.

A case series of two transgender women and two transgender men who had been diagnosed with GD and a comorbid schizophrenia-related disorder were successfully treated with GA treatment. The minimum follow-up period was 3 years.

Although the GA treatment was initially complicated by the ongoing presence of mild psychotic symptoms, patients ultimately experienced stabilization of these symptoms and a satisfactory adjustment to their new gender.

"There has been much controversy about offering a transgender trajectory to individuals with a psychotic condition because, traditionally, gender dysphoria has been regarded as a gender delusional state in those with psychosis," Dr Meijer told Medscape Medical News.

"These cases show that gender-affirmative treatment is viable when handled appropriately and that it does not cause psychotic decompensation — if anything, the psychotic complaints improve," she said.

The study was published online April 1 in LGBT Health.

Ethical Right Withheld

Although GA treatment "should be an ethical right of all individuals with GD," it has been withheld from many patients with psychosis because psychiatric illness has been considered a negative prognostic feature of GA treatment, the authors write.

GD is sometimes regarded as a product of impulsivity in those with coexisting psychosis or a "mask" for schizophrenia, they add. Additionally, some clinicians have been concerned that hormonal interventions may trigger or exacerbate psychotic symptoms and that individuals with GD and psychosis are at greater risk of developing future regrets about their gender transition.

"To date, there is little evidence to counterbalance these concerns, as people with psychosis are often excluded from studies for methodological reasons," the authors note.

"Exclusion of individuals with psychosis from GD studies makes it difficult to estimate the true prevalence of psychosis in individuals with GD," Dr Meijer said. "But based on the available evidence, there is no reason to assume that the prevalence of psychotic symptoms in gender-dysphoric individuals is either higher or lower than the 3% to 4% in the general population."

The authors undertook the present case series to "extend existing knowledge" about the complexities and challenges of administering GA to this population and to offer recommendations to overcome these challenges. The patients in this series were treated by the authors themselves.

"We wanted to look at individuals who had already completed their transgender trajectory to present the challenges and pitfalls facing this largely unknown and often untreated group during the treatment process and to see whether the concerns about outcomes and future regrets were present," Dr Meijer said.

No Increase in Psychotic Symptoms

The four individuals (aged 27 to 57 years) included in the case series had a DSM-IV diagnosis of gender identity disorder (GID). GID was renamed GD in DSM-5. Their coexisting primary psychotic disorders were schizophrenia, schizoaffective disorder, or psychosis not otherwise specified.

GA treatment consisted of the administration of gender-affirming hormones, possibly combined with GA surgery. Individuals had to have undergone the typical diagnosis procedure of regular sessions over a minimum of 6 months and the completion of a battery of psychological tests. A family member or acquaintance was required to provide collateral history of the patient.

In all four cases, the longing to be the opposite gender from that assigned at birth was present from an early age (in one patient, during years as a toddler, in two patients at age 4 years, and one patient at age 7 years). All individuals continued to experience this longing throughout childhood and adolescence and often played as being the opposite gender. Symptoms of psychosis typically appeared in mid-adolescence to early adulthood. All four individuals first revealed their GD to mental health staff during hospitalization.

The four individuals underwent GA, which was staged more slowly, owing to their psychiatric comorbidity. They underwent a successful transition with no subsequent regrets and were adherent with their GA and psychiatric treatments.

"There was no association in any of our cases between GA treatment and an increase in psychotic symptoms," the authors write. "Our results do not support reports that the effects of hormonal or surgical GA interventions may trigger psychosis."

The authors note several "complexities" in delivering GA treatment, including the fact that the patients revealed their GD feelings only after the onset of psychotic or prodromal symptoms. Moreover, gender themes were sometimes present in psychotic beliefs, leading to the question of whether the patient was experiencing GD or gender delusion.

"Distinguishing between the two can sometimes be tricky," Dr Meijer acknowledged, so "it is important for a family member or acquaintance to provide collateral history to substantiate the patient's long-standing desire to be the gender opposite from that assigned from birth."

Additionally, there is a difference between "gender confusion" and "gender dysphoria," she noted.

"A man with GD will say, 'I am a woman born with the physical features of a man, but I feel like a woman in every respect but my body,' while someone with gender confusion might be unclear about his or her gender or might have more bizarre gender-related delusional states."

Few Contraindications to Gender Transition

William Byne, MD, PhD, editor-in-chief of the peer-reviewed journal LGBT Health and associate professor, Icahn School of Medicine at Mount Sinai, New York City, said that the cases "confirm what many of us who are familiar with GD have already thought and known, which is that people with coexisting GD and psychosis may not be adequately diagnosed and that overt manifestations of the GD may not present until after psychosis onset."

Commenting on the case series for Medscape Medical News, Dr Byne, who was not involved with the study, said that many people "may experience themselves as belonging to the other gender but may not come out as transgender until adulthood.

"Since schizophrenia has its onset in late adolescence and early adulthood, it is not surprising that some individuals with GD may not have expressed this prior to that point," he said.

"In general, if a person meets DSM criteria for GD, there are very few contraindications to supporting the person for gender transition," he emphasized.

Active psychosis, however, is a contraindication, he warned. "The psychosis needs to be under control prior to transition, and the individual needs to be stable and adherent with the medication regimen."

He noted that "although some psychotic symptoms may increase during transition, as the individual adjusts to his or her new body, mood and psychotic symptoms may actually improve post transition because the person is no longer dealing with GD."

Dr Meijer agreed, adding that the usual timing of the transitional trajectory has to be considerably slower for this population. "You cannot rush through the steps, even if it takes months to years longer than what it would take in those without psychosis."

Additionally, "it is particularly important to work with families and caregivers who may be skeptical about the process and may need the support and assistance of mental health practitioners."

She emphasized that there is "a great need for the development of official guidelines to lower the barriers to gender dysphoria treatment in this population.

"I hope that patients with gender dysphoria and psychotic comorbidity will no longer be excluded from gender dysphoria trials and that the findings of our small case series can be replicated," she said.

The study received no funding. The authors have disclosed no relevant financial relationships.

LGBT Health. Published online April 1, 2017. Full text

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