Clinical Context

Transgender and gender-diverse (TGD) individuals have high rates of psychopathology both overall and compared with cisgender persons. Nearly all evidence to date has been limited by reliance on self-reported, unstructured measures and assessment of isolated psychiatric symptom domains, which limits understanding of the mental health needs of TGD individuals.

Identifying differences in diagnostic profiles between TGD and cisgender partial hospital patients could provide additional information about the psychiatric needs of TGD patients in clinical settings. Previous literature has shown the importance of comprehensive, structured, assessments rather than relying on self-report.

Study Synopsis and Perspective

TGD individuals with mental illness appear to have higher rates of posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD) compared with their cisgender counterparts, new research shows.

Although mood disorders, depression, and anxiety were the most common diagnoses in both TGD and cisgender patients, "when we compared the diagnostic profiles [of TGD patients] to those of cisgender patients, we found an increased prevalence of PTSD and BPD," study investigator Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, Rhode Island, told Medscape Medical News.

"What we concluded is that psychiatric programs that wish to treat TGD patients should either have or should develop expertise in treating PTSD and BPD, not just mood and anxiety disorders," Dr Zimmerman said.

The study was published online September 26 in the Journal of Clinical Psychiatry.

'Piecemeal Literature'

TGD individuals "experience high rates of various forms of psychopathology in general and when compared with cisgender persons," the investigators note.

They point out that most empirical evidence has relied on the use of brief, unstructured psychodiagnostic assessment measures and assessment of a "limited constellation of psychiatric symptom domains," resulting in a "piecemeal literature wherein each piece of research documents elevations in one--or a few--diagnostic domains."

Studies pointing to broader psychosocial health variables have often relied on self-reported measures. In addition, in studies that used a structured interview approach, none "used a formal clinical interview procedure for the assessment of psychiatric diagnoses," and most focused only on a "limited number of psychiatric conditions based on self-reports of past diagnosis."

The goal of the current study was to use semistructured interviews administered by professionals to compare the diagnostic profiles of a samples of TGD and cisgender patients who presented presenting for treatment at a single naturalistic, clinically acute setting--a partial hospital program.

Dr Zimmerman said that there was an additional motive for conducting the study. "There has been discussion in the field as to whether or not [TGD] individuals all have borderline personality disorder, but that hasn't been our clinical impression."

Rather, Dr Zimmerman and colleagues believe that TGD people "may have had more difficult childhoods and more difficult adjustments in society because of societal attitudes and have to deal with that stress, whether it be microaggressions or overt bullying and aggression," he said. The study was designed to investigate this issue.

In addition, studies conducted in primary care programs in individuals seeking gender-affirming surgery have "reported a limited number of psychiatric diagnoses, but we were wondering whether, amongst psychiatric patients specifically, there were differences in diagnostic profiles between transgender and gender diverse patients and cisgender patients. If so, what might the implications be for providing care for this population?" Dr Zimmerman added.

TGD Not Synonymous With Borderline

To investigate, the researchers administered semistructured diagnostic interviews for Diagnostic and Statistical Manual of Mental Disorders, fourth edition, disorders to 2212 psychiatric patients (66.0% cisgender women, 30.8% cisgender men, 3.1% TGD; mean [SD] age, 36.7 [14.4] years) presenting to the Rhode Island Hospital Department of Psychiatry Partial Hospital Program between April 2014 and January 2021.

Patients also completed a demographic questionnaire including their assigned sex at birth and their current gender identity.

Most patients (44.9%) were single, followed by 23.5% who were married, 14.1% living in a relationship as if married, 12.0% divorced, 3.6% separated, and 1.9% widowed.

Almost three quarters of participants (73.2%) identified as White, followed by Hispanic (10.7%), Black (6.7%), "other" or a combination of racial/ethnic backgrounds (6.6%), and Asian (2.7%).

There were no differences between cisgender and TGD groups in terms of race or education, but the TGD patients were significantly younger compared with their cisgender counterparts and were significantly more likely to have never been married.

The average number of psychiatric diagnoses in the sample was 3.05 (standard deviation, 1.73), with TGD patients having a larger number of psychiatric diagnoses than their cisgender peers (an average of 3.54 ± 1.88 vs 3.04 ± 1.72, respectively; t=2.37; P=.02).

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) were the most common disorders among both cisgender and TGD patients. However, after controlling for age, the researchers found that TGD patients were significantly more likely than cisgender patients to be diagnosed with PTSD and BPD (both Ps<.05)

"Of note, only about one-third of the TGD individuals were diagnosed with BPD, so it is important to realize that [TGD] identity is not synonymous with BPD, as some have suggested," noted Dr Zimmerman, who is also the director of the Outpatient Division at the Partial Hospital Program, Rhode Island Hospital.

A Representative Sample?

Commenting for Medscape Medical News, Jack Drescher, MD, distinguished life fellow of the American Psychiatric Association and clinical professor of psychiatry, Columbia University, New York City, called the findings "interesting" but noted that a limitation of the study is that it included "a patient population with likely more severe psychiatric illness, since they were all day hospital patients."

The question is whether similar findings would be obtained in a less severely ill population, said Dr Drescher, who is also a senior consulting analyst for sexuality and gender at Columbia University and was not involved with the study. "The patients in the study may not be representative of the general population, either cisgender or transgender."

Dr Drescher was "not surprised" by the finding regarding PTSD because the finding "is consistent with our understanding of the kinds of traumas that transgender people go through in day-to-day life."

He noted that some people misunderstand the diagnostic criterion in BPD of identity confusion and think that because people with gender dysphoria may be confused about their identity, it would mean that all people who are transgender have borderline personality disorder, "but that's not true."

Dr Zimmerman agreed. "The vast majority of individuals with BPD do not have a transgender or gender-diverse identity, and TGD should not be equated with BPD," he said.

No source of study funding. Dr Zimmerman and coauthors and Dr Drescher have disclosed no relevant financial relationships.

J Clin Psychiatry. Published online September 26, 2022.^[1]

Clinical Implications

• PTSD and BPD were more prevalent in TGD than in cisgender patients.
• Psychiatry programs interested in qualifying as Safe Zones and treating TGD patients should have or develop expertise in treating PTSD and BPD.
• Implications for the Health Care Team: It is important to ensure routine screening for these disorder domains is available and occurring in clinical settings.

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