ALLIES for the Journey

For people who are transgender, or even for those questioning their gender, the road to get to where they want – and need – to be is often a long one, with many difficulties along the way. Whether it’s before, during, or after a transition, people of any age may experience not only anxiety and fear of what lies ahead and how others may react, but rejection, discrimination, harassment, and even physical violence.

“The majority of patients that I have seen, particularly those who have lived as the gender they identify with, have faced some sort of aggression – or flat out been assaulted – because of their gender identity,” says Jeffrey Shelton, MD, chair of psychiatry at Middlesex Health. “Stress causes anxiety and depression. And I can recognize that an actual severe clinical depression can develop out of the microaggression, or even overt aggression, that transgender people often experience.”

With so much tumult affecting many transgender patients, he says, addressing not only the physical but the psychological and psychiatric challenges they face is key to their success and future happiness.

Fortunately, help is at hand.

For the past four years, the multidisciplinary team involved with Middlesex Health’s Transgender Medicine Program has been helping patients find their way through the process of dealing with their gender issues, offering wrap-around support that helps them feel safe, heard, and respected. The program is headed by medical director Katy Tierney, MSN, APRN, FNP-BC, an endocrinology specialist who treats hormonal and glandular issues and is widely known for her work. Middlesex cares for more than 900 transgender or gender non-conforming patients, and its program continues to grow.

The program’s staff includes not only Dr. Shelton but a wide variety of practitioners, including other mental health providers, primary care providers, physical therapists, speech therapists, urologists, OB/GYNs, plastic surgeons, occupational therapists and clinical social workers—just to name a few. Clinical psychologist Angel Roubin, Psy.D., LPC, serves as the program’s navigator and runs a monthly transgender community support group.

When the Transgender Medicine Program began, says Dr. Roubin, “we identified providers in various departments that we felt should be involved. We really wanted to pull together a team to offer comprehensive care. A lot of my patients have started out here with one service, but then slowly decided that they wanted everyone [all of their medical providers] to be in the same healthcare system. It certainly makes collaboration easier.”

As her title implies, Dr. Roubin helps patients to navigate the health care system, make complex care decisions, and cope with emotional issues that might arise before, during, or after transition.

She works closely with Dr. Shelton, who has treated transgender or gender non-conforming patients throughout much of his career and considers himself not only a physician but an advocate for his patients. When patients seek him out, or are referred to him, Dr. Shelton says, “much of that initial visit is just to try to convey an understanding and empathy, and to let them really know that this is a safe place. This is the place where they can get help. This is a place where they can heal, and we have an army of people who support us, who can also help patients along this journey. It’s interesting – very rarely in psychiatry do I say, ‘Go see endocrinology, occupational therapy, and speech therapy as part of the treatment plan.’ But that is absolutely part of the treatment plan.”

While endocrinology offers hormone replacement therapy, other medical specialties can also improve a person’s mental and physical wellbeing. For example, occupational therapist Lisa Gramlich, PT, IMT-C encourages patients to continue exploring their gender identity, affirms their feelings and experiences, and helps them transition into their preferred gender roles. She also teaches them how to deal with bullying and prevent job loss, among other things. Speech and language pathologist Rebecca Burrell, MS, CCC-SLP assists patients in managing and adapting to changes in their voice as they undergo hormone therapy.

“They’re both just incredibly passionate” about the work they do, Dr. Shelton says of Gramlich and Burrell. “There was this amazing story that Rebecca told about how she’d been working with a patient and in the last session, the patient was reading a story about saying goodbye to her old voice. And literally, as she is telling us this, all of us are crying. It was just so touching.”

Emotions can run high during a transition journey, both in positive ways and negative ones. Dr. Shelton says for patients, the stress and despair of feeling they are living in the wrong body, being bullied or rejected, and fearing retribution or violence can be overwhelming. “Studies have shown that transgender people are probably the highest risk group demographic for suicide of any demographic in the U.S.,” he notes.

A 2014 study found that 41% of transgender people attempted suicide at least once. Those figures were backed up by a 2018 American Academy of Pediatrics survey, which revealed that nearly 51% of transgender male teen respondents and 30% of transgender female teen respondents had tried to commit suicide at some point. Almost 42% of nonbinary teens, along with 28% of questioning adolescents, also said they had tried to kill themselves.

“The national average is around 7%, so that’s a dramatic increase, and higher than people who live with major depression. That’s a big deal,” says Dr. Shelton.

Patients wishing to undergo gender-affirming surgery are required by their insurance companies to undergo mental health evaluations first, but the benefits of seeing a mental health provider extend far beyond getting approval for those procedures. Drs. Roubin and Shelton say that psychiatric and psychiatric support can be extremely affirming for patients, who often feel that they are “wrong” or “less-than” for having gender dysphoria, due to the way they are judged and treated by society.

At Middlesex Health, patients are reassured that being transgender or gender non-conforming is not a mental illness, and that, if anything, it’s society that has the problem with their identity. In essence, many people need to learn to be more understanding, accepting and supportive.

Still, it can be difficult, even heart-wrenching, to work through all of the obstacles these patients have to face. Some are rejected by family members – even by their parents. Others may find that friends and acquaintances distance themselves or report being treated rudely by strangers. Dr. Shelton says many patients realize they are transgender when they are middle-aged or older, and face having to reinvent their entire lives. Some are married with children and must face possible lack of acceptance or collapsed relationships involving the people they love the most. Most don’t know other transgender people, so they feel extremely isolated. Talking things out with a psychiatrist or psychologist can be a lifeline, helping patients make peace with themselves and their decisions.

Middlesex Health’s monthly gender discussion group – for transgender people only – is another key resource. Says Dr. Roubin, “I’ve been hearing from [members] that, ‘This is the one time of the month in which we feel safe.’ Or, “It’s the only time of month I can come out looking like this.’ It’s kind of heartbreaking. It is.” But the group is a valuable source of both professional and peer support. A separate support group for parents, friends and allies is also held monthly.

Dr. Shelton notes that while he is an advocate for transgender and nonbinary patients, he also has empathy for parents or other loved ones who are struggling with their new reality.

“I want to be compassionate to both sides,” he says. “It absolutely is a transition for the family as well. We’ve had people come to our [family/ally] support group who say, ‘I love my child, but I’m having a really hard time calling her him.’ And we’ll say, ‘I’m so glad you’re here. Let’s talk about that; what are your concerns and what are your fears?’ Because there is so much stigma surrounding being trans, or non-conforming, they may have a hard time reaching out to their friends or other people in their lives to talk about it. They may be isolated in their own way. That’s why support groups are great because it’s like, “Here’s a whole other group of parents who will say, ‘Yup, I’ve been there.’ ”

As difficult as it may be to accept, at first, that a daughter has become a son, or a brother has become a sister – and as hard as it may be to remember to use new names and different pronouns, they say, it’s crucial that the family accepts and supports that person in their journey.

“I have had family members come in who were hostile and unwilling to change,” says Dr. Shelton. “And I was like, ‘You have a choice: a dead son or a live daughter. That’s your choice.’ I’ve seen patients just in huge crisis after rejection from a family member, time and time again, and I’ve had some parents say, ‘Okay, look, you’re right. I’m good.’ That’s really what this boils down to. Your support is that important. Your child has never needed you more – except maybe when they were a week old – than they do right now. They need you in a really intense way, and they’re going to lean on you, because who knows who else they might have in their life? You’ve always been there for them, so to have that yanked out [from underneath them] is really hard.”

At the same time, he says, “it’s okay for you to need a transition too. But please don’t try and do that by yourself. Go to the support groups. I have a friend whose son came out as transgender and this woman loves her son more than anything but went to a lot of support groups to get there, and now she argues with TSA agents at the airport.”

While it’s sometimes easy to focus on the struggles, a tremendous amount of good often comes from the whole process.

Dr. Roubin says once a patient starts hormone therapy or undergoes gender-affirming surgery, they typically feel a sense of relief that they’re finally becoming “themselves.” Trans males who have top surgery may feel that a weight has been lifted, both physically and emotionally, for example. “But I think that even beyond that, just in terms of their emotional experience, people do feel better. And that’s our goal, to try to serve people along that path. So it’s not all doom and gloom.”

Adds Dr. Shelton, “What an amazing privilege it is to watch the journey and see someone grow in self-acceptance and love, and develop a community of supports – and to see the same thing for family members who are just, like, ‘I love my kid, and I will do anything for my child. This isn’t easy but I love my daughter, and before, it was always my son.’ To see that journey, to me, it’s just so exciting.”

Dr. Roubin points out that not every trans person experiences gender dysphoria – “particularly younger trans people or people who identify as being binary; they’re down with who they are. They might say to me, ‘I just want to get on hormones to feel a little more in sync with that, but overall, I feel fine,’” she says.

“I’ve even heard people use the phrase ‘trans euphoria,’ once they come to a place where they feel comfortable. They’re not dysphoric at all. They’re quite happy. One of the hardest parts is getting them to come see you initially.”

She says trans or questioning people should know that employees throughout Middlesex Health have received extensive training in gender sensitivity, so patients don’t encounter the kinds of uncomfortable questions and situations they may have experienced in other healthcare settings.

And Dr. Roubin is there to guide them through the process. “I always try to make the point of acknowledging that not everyone’s journey is the same, and I don’t have an agenda for you. However, if and when you’re ready, this is how we can help.”

“Everyone’s transition is individual,” agrees Dr. Shelton. “Sometimes, people don’t do hormones. Sometimes they change their name; sometimes, they don’t. I think that’s beautiful. That’s great. I’m like, ‘Where are you? I want to meet you there as a human being and as a person.’ ”

For more information, visit middlesexhealth.org/transgender and middlesexhealth.org/lgbtq.