Supporting Trans Youth Who May Lose Gender-Affirming Treatment

What’s happening – Last week, Arkansas became the first state to ban gender-affirming treatment for transgender people under age 18 after the state legislature overturned Gov. Asa Hutchinson’s veto of the bill. As a result, clinicians will be prevented from providing care such as puberty blockers, hormone therapy, surgery, and referrals to other providers, and there is no grandfather clause for youth who are currently transitioning.

Similar bills in 14 other states have been introduced that would prohibit some forms of gender-affirming care (GAC) for those under 21 years of age. Some proposed state bills even define such care as child abuse, punishing parents and medical providers for providing these treatments.

Trans youth advocates expressed concern that restricting GAC could cause an increase in suicides and mental health disorders among youth. A recent American Academy of Pediatrics report cited a CDC survey stating that 1.8% of high school students identify as transgender and 35% reported that they had attempted suicide. The AAP report also cited a study from Pediatrics that found the risk of suicide decreases when individuals receive GAC.

Reports & Perspectives

  • USA Today details the Arkansas bill and others under consideration and reports on advocates’ warnings about the mental health implications of the bills.
  • The Hill and Stat reported on the health risks that GAC bans could have for trans youth.
  • Nearly 600,000 physicians and medical students oppose legislation that “interferes in or criminalizes patient care” in a statement signed by the American Psychiatric Association, the American Academy of Pediatrics, and others.
  • The Human Rights Campaign (HRC) released an open letter signed by child health and welfare groups that rejects current legislation targeting trans youth and LGBTQ people and that expresses concern for the harm the laws could cause if passed. The HRC also reports that 2021 is a record-breaking year for anti-trans legislation.
  • The American Psychiatric Association (link is a downloadable PDF), the American Academy of Pediatrics, the Endocrine Society, and the World Professional Association for Transgender Health support gender-affirming care for trans youth, saying that earlier support for young people leads to better health outcomes and that denial of such care may increase the risk of anxiety, depression, and suicidal ideation and attempts.
  • In addition to state proposals to ban GAC, many states are considering, and some have passed, bills restricting trans girls from participating in school sports. Kate Oakley, state legislative director and senior counsel for the Human Rights Campaign, said of the legislation, “It’s really invalidating transgender identity,” in an ABC News report.

Related studies –

  • Gender-incongruent youth who received GAC when younger than 15 experienced a lower risk of depression, self-harm, and suicidal ideation and attempts when compared with adolescents 15 or older who received care, according to research by Sorbara et al that studied 300 individuals.
  • A study by Soll et al described the use of the gender affirmation model, which promotes assessment and personalized guidance with access to multidisciplinary health services when treating trans youth in Brazil.

Resources

  • The Trevor Project, which provides crisis intervention and suicide prevention services to LGBTQ youth, presents a research brief about gender-affirming care. The organization offers several ways for people to get help – via phone, texting, chat – on their website.
  • The Trans Lifeline provides a hotline for trans people, as well as a Friends and Family Hotline for those who need help supporting a trans loved one.
  • Additional resources for supporting trans youth are available with the Human Rights Campaign, the CDC, and the Trans Youth Equality Foundation.

The conversation

  • @NHeLP_org (National Health Law Program) tweeted: “Gender-affirming care is essential for happy & healthy kids. States like Arkansas are wrong. Wrong on the science, wrong on the evidence … just plain wrong” and linked to this Health Law article.
  • @WilliamsPolicy (the Williams Institute, a think tank at UCLA Law dedicated to research on sexual orientation and gender identity law) tweeted: “Our new study finds 45,000 transgender youth are at risk of losing access to gender-affirming care because of proposed state bans.”
  • @ACLU tweeted: “‘If they put this bill through, we’re going to lose kids.’ David Fuller, a father of a transgender daughter, spoke out against Alabama’s HB 1, a bill that would deny gender-affirming care.”

In practice – More on the Trevor Project. See also recent research on clinical bias in diagnosing lesbian, gay, and bisexual individuals with a borderline personality disorder.

Psychedelics: R-Ketamine Drug in Development for Major Depression

What’s happening – A collaboration between Otsuka Pharmaceutical and Perception Neuroscience (an atai Life Sciences company) will develop Perception’s lead molecule, PCN-101 (R-ketamine), in Japan as a possible treatment for major depressive disorder (MDD) and treatment-resistant depression (TRD). Perception is also developing PCN-101 for the treatment of TRD outside Japan.

PCN-101 is “a formulation of R-ketamine, a single isomer of ketamine that belongs to a new generation of glutamate receptor modulators, being developed as a rapid-acting antidepressant (RAAD),” according to the news release. Atai’s website describes R-ketamine (also known as arketamine) as ketamine’s “often overlooked R(-) enantiomer,” and the company believes that R-ketamine has the potential to be longer-lasting, less likely to be abused, and more effective as a RAAD than S-ketamine (or esketamine, the compound in Janssen’s Spravato for MDD and TRD).

Why it’s complicated – Psychedelic-assisted treatment is complicated because the drugs typically used (eg, ketamine, MDMA, psilocybin, LSD, and ibogaine) remain illegal in most of the country. Oregon and Washington, DC, voted in November 2020 to decriminalize the possession and personal use of psilocybin and other psychedelics, following some cities that had previously done so such as Denver, Ann Arbor, MI, and in California, Oakland, and Santa Cruz.

Reports & Perspectives

  • A recent study by Passie et al in European Neuropsychopharmacology compares ketamine with its S- and R-enantiomers and the different psychological effects related to treating depression.
  • Listen to NPR’s recent report on how ketamine and other psychedelics are being used to treat psychiatric conditions.
  • An article from Medscape provides an overview of global psychedelic therapy research.
  • California is considering decriminalizing psychedelics like psilocybin, MDMA, LSD, ketamine, DMT, and mescaline for personal and therapeutic use under Senate Bill 519. The Sacramento Bee reported last week that the state’s Senate Public Safety Committee voted to approve the bill, which will now go before the Senate Health Committee.
  • Clinicians who are not trained in psychedelic therapy may have questions about how to discuss the topic with patients. A recent paper by Gorman et al presents a framework for working with patients who use, intend to use, or have used psychedelics in the Psychedelic Harm Reduction and Integration approach. Compass Pathways has also developed a training program for clinicians learning to administer psychedelic-assisted therapy.
  • Vice’s @shayla__love tweeted her article about the “tension” between psychedelic treatments for addiction and 12-step programs, which demand abstinence from any drug. mappingthemind (the Toronto Psychedelic Conference) replied to @shayla__love and linked to this systematic review, saying “there were some studies in the 50s and 60s that support the idea that the combination of the 12-step model and psychedelic therapy works well to treat substance use disorders.”

In practice – Clinical considerations about preparing to administer psychedelic-assisted therapy for MDD. The potential of psilocybin to help people with MDD and other disorders. What to do when a client wants to try psychedelics (see our Psy–Q below).

Psy-Q: This Week's Challenge

How can clinicians advise patients who ask about psychedelic use? Andrew Penn, MS, NP, PMHNP-BC, answers.

Get the Answer

PTSD After COVID-19 Infection: Yet Another Long COVID Symptom

What’s happening – One-third of COVID-19 survivors appear to develop PTSD, according to a study of 381 patients in Italy who visited the emergency department for COVID treatment. Most patients required hospitalization, the average stay was 18 days, and patients were assessed within 30 to 120 days of recovery.

Those diagnosed with PTSD were more likely to be women, had a history of psychiatric disorders, reported delirium and agitation during acute illness, and had more persistent medical symptoms post-COVID-19 infection. The researchers noted that their finding of PTSD prevalence in just over 30% of COVID-19 survivors aligns with the PTSD occurrence rate (32%) after the previous SARS and MERS coronavirus pandemics.

Why it’s complicated – In a separate study of veterans, researchers looked at the association of PTSD symptoms with post-traumatic psychological growth (PTG), which is a positive psychological change resulting from highly challenging circumstances. Examples of PTG include increased personal strength, appreciation of life, improved social relationships, and spiritual changes. Of the 3,078 veterans studied, just over 43% reported moderate or greater levels of COVID-19–associated PTG (most commonly greater appreciation of life, improved social relationships, and increased personal strength), and those who screened positive for COVID-19–associated PTSD symptoms had a higher prevalence of PTG (71.9%).

For more on PTG and COVID-19, see this JAMA viewpoint article, “Pandemic-Driven Posttraumatic Growth for Organizations and Individuals.”

Reports & Perspectives

  • A related study by Tarsitani et al looked at PTSD in COVID-19 survivors 3 months after hospitalization and found that 10.4% of the sample (n=115) had PTSD and 8.6% were diagnosed with subthreshold PTSD. Previous psychiatric diagnosis and obesity were risk factors for developing PTSD.
  • Reports from CNN and Global News describe the challenges of PTSD for COVID-19 survivors.
  • The University of Michigan’s Department of Psychiatry provided a fact sheet about PTSD and COVID-19.
  • Research into the mental health burden of frontline healthcare workers shows they are at risk for PTSD as well, and authors call for early intervention, serologic testing, and better ways to identify and provide treatment for those who are at risk for developing PTSD, depression, and anxiety.
  • Looking at treatment approaches, a study protocol appearing in Medicine describes a systematic review and meta-analysis that will examine the effects of smartphone-based app intervention on post-COVID PTSD, while a viewpoint article in Frontiers in Psychiatry found that a mindfulness-based approach could help manage and mitigate mental health issues during the pandemic.
  • In related COVID-19 news, a recent Lancet study found that one-third of COVID infected people developed a neurological or psychiatric issue within 6 months, and the risks were higher among people with severe COVID-19 that required hospitalization.
  • @UTDallasNews tweeted “As COVID-19 cases continue, health care workers will face physical, emotional, cognitive and behavioral issues. Organizational PTSD will become the greatest challenge for health care leaders,” and linked to this article.
  • @ARNS_UK (Association of Respiratory Nurse Specialists) tweeted “People with long #COVID at high risk of depression and PTSD,” with a link to this European Respiratory Society paper.

In practice – How to manage vicarious trauma and burnout. More on the effects of long COVID, including dementia and psychosis. Plus, the long-term impact of the pandemic on long-term care residents.

Last Updated: Jun 3, 2021