Introduction

Transgender identity is not a mental illness; however, mental health assessment and care is an integral part of transgender care. Transgender people may present with gender dysphoria, for help in exploring their gender identity, or for mental health conditions like depression, anxiety, or substance abuse that may be related to societal prejudice and trauma, which are commonly experienced by trans people. Misunderstanding or failure to recognize an individual’s affirmed gender may worsen their mental health symptoms while acknowledgement of their name and/or gender may help to reduce depression and suicidal thinking.

The role of the mental health provider is to provide a safe and supportive space, incorporating the principles of cultural humility in the provision of care to patients. In addition to providing mental health care, providers have a key role in assessing clients/patients for transition-specific medical and surgical care. This role is described in detail by the World Professional Association for Transgender Health (WPATH) in their standards of care (SOC), currently in its seventh version.

Evolution of the DSM and Diagnostic Criteria in DSM 5

A diagnosis of Transsexualism entered the Diagnostic and Statistical Manual of Mental Disorders (DSM) with the publication of DSM III in 1980. The criteria for diagnosis included discomfort with one’s assigned sex, dressing as the other sex, and a desire to change primary and secondary sex characteristics. In DSM III-R, published in 1987, Transsexualism was placed in the category of Disorders Usually First Evident in Infancy, Childhood, or Adolescence. Gender Identity Disorder (GID) of Childhood was a diagnosis given to prepubertal children in the DSM III and III-R. The DSM III-R also included a diagnosis called Gender Identity Disorder (GID) of Adolescence or Adulthood, Nontranssexual Type .

In the DSM IV, published in 1994, diagnoses of Transsexualism and GID of Children were both replaced with GID alone, with criteria for adolescents and adults and a separate set of criteria for children, in the Sexual and Gender Identity Disorders chapter. GID in Adolescents and Adults in the DSM IV and DSM IV-TR (2000) is characterized by “a strong and persistent cross-gender identification” and a persistent discomfort with one’s sex or gender role, a desire for medical or surgical treatment, and a belief that one was “born the wrong sex.” GID in Adolescents and Adults was criticized for a number of reasons. First, the diagnosis was binary, with references made to a “cross-gender identity” and “opposite sex.” Second, a belief that one was born the wrong sex was considered inaccurate criteria because this type of belief could persist posttransition. Third, using this diagnosis, a desire for treatment was considered a symptom of a disorder, rather than a healthy response to distress. And last, the name of the diagnosis itself implied that transgender identity was a mental disorder. Furthermore, the chapter on Sexual and Gender Identity Disorders included a section on paraphilias, which included transvestic fetishism and other paraphilias, some of which involved criminal behavior, such as pedophilia.

The GID in Children diagnosis in the DSM IV and DSM IV-TR was also criticized. GID in Children criteria included gender nonconforming behaviors. Only one criterion was related to cross-gender identity, and it was not required to make the diagnosis. As a result, persistent gender nonconformity in youth without transgender identity could be assigned the diagnosis. One of the biggest criticisms of persistence and desistance of gender dysphoria from prepubertal childhood into adulthood is that several studies examining this used the GID in Children diagnosis, which could be made with gender nonconforming behavior alone, without transgender identity.

The most recent version of the DSM is the DSM 5, which was published in 2013, and replaced GID with a diagnosis of Gender Dysphoria ( GD ). In addition, GD was removed from the chapter that included the paraphilias. The most significant changes from the GID diagnosis to GD include the following: (1) As indicated by the terminology change, GD is the distress related to the difference between one’s assigned gender and one’s experienced gender, rather than the identity that is associated with being transgender. An individual has the diagnosis as long as there is clinically significant distress or social/occupational impairment related to the incongruence between their identity and how they were born. The diagnosis does include a posttransition specifier, which allows for ongoing treatment, for example, with hormones. (2) Unlike GID , which describes a binary trans identity and transition, GD includes nonbinary people. Identity and transition do not have to be related to the “opposite” sex, but rather can be related to any identity along the gender spectrum, including identifying as nonbinary or agender ( Table 2.1 ).

The World Health Organization released the International Classification of Diseases, 11th Revision (ICD 11) in 2018. ICD 11 replaces transsexualism from the ICD 10 with Gender Incongruence. Like GD , Gender Incongruence includes nonbinary gender identities and reduces the length of duration of symptoms to several months to formally make the diagnosis. Gender Incongruence is not distressed-based like GD and belongs in a Conditions Related to Sexual Health chapter, apart from the mental disorders, so as to not psychopathologize trans identity ( Table 2.2 ).

WPATH Requirements for Mental Health Professionals

The WPATH has been publishing consensus guidelines for care since 1979. WPATH released the SOC version 7 (SOC 7) in 2011, and the SOC 8 will soon be published. The WPATH SOC is an easily accessible document, and it is available in many languages. The SOC are guidelines that outline the role of the licensed and qualified mental health professional who performs mental health assessments for transgender patients seeking medical and surgical transition. Per the SOC, these qualified mental health professionals can have either a master’s or doctoral degree. Assessments may be done with clients or patients in therapy, or people may seek assessments only. Importantly, psychotherapy is not required for these assessments.

The assessment for hormones under the SOC may be done by a mental health professional or, alternatively, a knowledgeable primary care provider or endocrinologist. Criteria for adults to initiate hormone therapy include persistent gender dysphoria, the capacity to give informed consent, and “reasonably well-controlled” mental illness, if present. Individuals who are exploring gender identity or who are addressing their gender dysphoria for the first time may present with significant distress that may be relieved with social transition and the initiation of hormones. Therefore it is important for mental health providers to recognize when this distress should not delay referral for hormone therapy. Conversely, patients with concurrent psychiatric conditions like bipolar disorder or schizophrenia may benefit from stabilization prior to transitioning. The risks and benefits of starting medical transition versus delaying initiation of medical care must be weighed under these circumstances. The ability of the person to give informed consent should be unimpaired, and the benefits of initiation of hormones should outweigh the risks. In clinical practice, stabilization of mental illness and substance abuse often happens concurrently with hormonal transition.

For chest surgery, the SOC require one letter of recommendation and support from a mental health professional. Similar to initiation of hormones, the adult patient must have persistent gender dysphoria and the ability to give informed consent, and concurrent mental illness must be relatively well controlled. For some, chest surgery comes as an early step in transition and may occur before social transition or treatment with hormones. For example, a transmasculine person or trans man may wish to have chest surgery before social transition, because breast binding is uncomfortable and may not be sufficient for the individual to feel comfortable presenting publicly as male. Significant chest dysphoria may occur in individuals assigned female at birth who do not want to start testosterone; these individuals may identify as nonbinary. For trans women, hormone treatment for 1 year is recommended but not required for feminizing mammoplasty. Significant breast tissue development may occur on feminizing hormones, so for some people, surgical augmentation may not be necessary.

For genital surgery, two independent assessments and letters from mental health professionals are required. For adults, persistent gender dysphoria and the ability to give informed consent are required. The person must be on hormones for the 1 year prior to surgery, unless it is clinically not indicated. Social transition to the gender with which the individual identifies is required for 1 year prior to surgery for vaginoplasty, metoidioplasty, and phalloplasty but not for orchiectomy or hysterectomy and/or oophorectomy.

As previously mentioned, the SOC recommend that mental illness must be “reasonably well-controlled” prior to chest or breast surgery and “well-controlled” prior to genital surgery. Note the wording is stronger for genital surgical guidelines than it is for medical transition and chest/breast surgery. Mental illness and substance abuse may impair the individual’s ability to give informed consent for surgery. Genital surgery in particular is associated with a significant risk of complications, and these should be well-understood before surgery is performed. Mental illness and substance abuse may impair the patient’s ability to keep appointments and follow perioperative instructions. Important postoperative issues, such as regular dilation after vaginoplasty, or being observant for complications may be compromised. Moreover, substance abuse may affect anesthesia or lead to postoperative withdrawal, which can have deleterious consequences. Lastly, tobacco smoking and other nicotine use impairs healing, and cessation needs to be addressed before surgery.