Social worker to therapist: Adaptation of role while addressing inequities in mental health care

Background: 2020 was a year of transformation in cystic fibrosis (CF) care. Many adults with CF started elexacaftor/tezacaftor/ivacaftor while COVID- 19 was unfolding. Occurring almost simultaneously, these two events created a dramatic shift in the disease landscape. Hospital admissions plummeted, and physical health improved. Clinic appointments turned virtual, and people with CF sheltered at home for months. These changes created opportunities for CF team members to adapt roles to meet evolving needs. Social work hours devoted to inpatient care, end of life, and discharge planning could be reallocated to other areas. Although many patients improved from a physical standpoint, mental health problems increased. Between 2020 and 2022, demand for mental health services increased exponentially, creating a national mental health crisis, but inequities in insurance coverage existed between physical and mental health care. Finding a mental health provider became an almost impossible task. This author sought to address insurance inequity and increased demand for mental health services by offering cognitive behavioral therapy (CBT) sessions to adults with CF to optimize their health andwellbeing. CBT is considered an evidence-based approach for most mental health problems. Method(s): Eight adults at the Stanford Adult CF Center were referred for CBT with social work from August 2021 to April 2022. Referrals were based on mental health crisis, mental health screenings, insurance barriers, and availability of mental health providers. Therapy sessions were offered via telehealth as part of the multidisciplinary care at the CF center. Patients were not billed for the sessions. The number of sessions was variable, with a mean of 10.5 sessions per patient. The frequency and content of sessions were tailored to patients' unique needs. Referrals were accepted on a continuous basis, space available. Mental health problems included anxiety, depression, alcohol use disorder, trauma, and gender dysphoria Results: All eight patients receiving CBT demonstrated significant improvement in mental health symptoms, as evidenced by a mean reduction in Patient Health Questionnaire-9 score of 3 and General Anxiety Disorder-7 score of 3.3. (Six of 8 patients were screened before and after therapy.) Other measures of improvement were patient selfreport as documented in therapy notes, sessions being tapered or discontinued as goals were met, and reduction in or stoppage of psychotropic medications. Conclusion(s): Mental health is a vital component of health and should be properly addressed as part of CF care. Although mental health care in CF has come a long way, patients continue to lack proper access to trained providers, especially those with expertise in CBT and CF. Given the current mental health crisis and shortage of therapists to meet newdemands, there are serious implications for long-term health outcomes for people with CF. As more studies are published demonstrating the effectiveness of CBT and other forms of therapy in the CF population, CF providers can adapt roles to implement new interventions in addressing mental health problems as part of CF care rather than referring patients to community providers who often are poorly positioned to meet their needs. The Stanford CF program will continue to use social work role to provide mental health servicesCopyright © 2022, European Cystic Fibrosis Society. All rights reserved

Healthcare clinician perspectives on the intersection of autism and gender dysphoria.

LAY ABSTRACT: Autistic people are more likely to have a gender identity which does not match their sex assigned at birth. Some people experience distress about their sex and gender not matching, which is called gender dysphoria. Such individuals may wish to attend a gender clinic to access healthcare support for gender dysphoria. Currently, there is limited evidence to help clinicians best support autistic people who need healthcare for gender dysphoria. We wanted to find out what healthcare clinicians think about working with autistic patients with gender dysphoria. We interviewed 16 clinicians who work in healthcare services with adults and young people who are autistic and experience gender dysphoria. We recorded the interviews and carefully analysed the content to find key themes. We found that clinicians worked with patients to try and better understand their experiences of gender dysphoria. Clinicians identified features of autism that they believed were related to gender identity and dysphoria including different thinking styles, social differences, and sensory sensitivities. Clinicians noticed that autistic people spoke about their gender in different ways to non-autistic people. Clinicians tried to adapt their practice to better meet the needs of their autistic patients. These adaptations tended to focus on differences in the assessment process, for example, offering longer or shorter appointments and changing their communication style. We conclude that clinicians were offering an individualised approach to autistic patients experiencing gender dysphoria. However, these clinicians were particularly interested in working with autistic people, and so may not be representative of the wider clinician population. Clinicians working in this area should receive training on autism adaptations and the intersection of autism and gender dysphoria.

Minority stress, pandemic stress, and mental health among gender diverse young adults: Gender dysphoria and emotion dysregulation as mediators

Gender diverse people in the United States are uniquely vulnerable to deleterious health outcomes because of long-enshrined systems of oppression and marginalization in American society. Trans young adults are especially vulnerable to these deleterious outcomes owing to their unique position in the life course. However, more research is needed on the mechanisms through which this marginalization contributes to mental health disparities in trans populations. Using a minority stress framework and online cross-sectional survey design, the current study examines potential mediators of the relationship between transgender identity-related distal stress and psychological distress from late May to early July 2020 in a sample of transgender young adults (N = 239;ages 18-29). More than half the sample scored above the K6 cutoff for severe psychological distress. Distal stress had a significant direct (beta = .17, SE = .04, t = 2.76, p = .006) and indirect effect on psychological distress. Distal stress was indirectly associated with psychological distress through gender dysphoria (beta = .04;95% CI [.001, .10]) and emotion dysregulation (beta = .16;95% CI [.09, .23]). COVID-19 pandemic stressors were also positively associated with psychological distress (beta = .36, SE = .12, t = 5.95, p < .001). Results highlight the significant mental health burden facing the trans community especially in the COVID-19 context, support a conceptualization of gender dysphoria as connected to experiences of oppression, and affirm the relevance of emotion dysregulation within minority stress frameworks. Mental health resources cognizant of the specific challenges experienced by trans young adults as well as policy changes that seek to address underlying structural transphobia in American culture and institutions are urgently needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved) Impact Statement This study surveying young adults with minority gender identities found (a) high rates of psychological distress during COVID-19, (b) that pandemic stress was associated with greater psychological distress, and (c) transphobic discrimination was associated with greater gender dysphoria and emotion dysregulation, which were both associated with greater psychological distress. This highlights the mechanisms underlying trans health disparities and the importance of recognizing transphobic/cisnormative experiences and systems of oppression when conducting research, creating policies, and/or providing services to support the transgender community. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Endocrine Management of Transgender Adults: A Clinical Approach

The attention to transgender medicine has changed over the last decade and the interest is most likely going to increase in the future due to the fact that gender-affirming treatments are now being requested by an increasing number of transgender people. Even if gender-affirming hormone therapy (GAHT) is based on a multidisciplinary approach, this review is going to focus on the procedures adopted by the endocrinologist in an out-clinic setting once an adult patient is referred by another specialist for ‘gender affirming’ therapy. Before commencing this latter treatment, several background information on unmet needs regarding medical and surgical outcomes should be investigated. We summarized our endocrinological clinical and therapeutic approaches to adult transgender individuals before and during GAHT based on a non-systematic review. Moreover, the possible relationships between GAHT, gender-related pharmacology, and COVID-19 are also reported.

Social Connectedness Matters: Depression and Anxiety in Transgender Youth During the COVID-19 Pandemic.

BACKGROUND: Gender-affirming and supportive relations for transgender youth are considered protective in terms of mental health. AIM: To describe how transgender youth perceived changes in their gender expression, in the course of the gender-affirming path, and the effect of social connectedness and social support on depression and anxiety during the pandemic. METHODS: In this cross-sectional study, transgender youth completed an online survey developed to evaluate the perceived changes in gender expression and affirmation path that occurred during COVID-19 and the age-stratified lockdown. Furthermore, we aimed to investigate the effect of social connectedness and social support on depression and anxiety in this population during the pandemic. The participants completed the following scales: Social Connectedness Scale Revised (SCS-R), Multidimensional Scale of Perceived Social Support (MSPSS), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI). The effect of lockdown on life conditions, gender expression, social and medical gender-affirming path, social connectedness, social support, depression, and anxiety levels were examined. Linear regression analyses were performed to evaluate the relationships between BDI and STAI scores and other variables. OUTCOMES: The relationship between the levels of perceived social connectedness, and social support, the pandemic-related changes in living conditions and depression and anxiety scores were calculated. RESULTS: A total of 49 transgender youth with a mean age of 20.53 ± 1.86 years were enrolled. Participants reporting discomfort at the place they live and who had difficulties concerning gender expression and affirmation had higher depression and anxiety scores and perceived lower social support from their family. Social connectedness score was a significant negative predictor of depression severity, whereas social connectedness and social support were both significant negative predictors of anxiety severity. CLINICAL IMPLICATIONS: Our results show increased adversity for transgender youth when connectedness with supportive people is diminished. During the COVID-19 pandemic, social connectedness and social support perceived by transgender youth are associated with better mental health. STRENGTHS AND LIMITATIONS: This is one of the first studies to evaluate the changes that occurred during the COVID-19 pandemic in transgender youth with relation to social support and connectedness, during an age-stratified lockdown. The main limitations were the small study size, skewed gender ratio and that the study sample came from a single gender clinic. CONCLUSION: As social connectedness and social support are significant predictors of depression and anxiety severity, special attention is needed to increase contact and support for transgender youth during the pandemic.

[Transgender health and healthcare during the COVID­19 pandemic: a cross-sectional online survey in German-speaking countries]. / Gesundheit und Gesundheitsversorgung von trans Personen während der COVID­19-Pandemie: Eine Online-Querschnittstudie in deutschsprachigen Ländern.

BACKGROUND AND OBJECTIVE: Since spring of 2020, the COVID­19 pandemic has disrupted our day-to-day lives and led to negative consequences in various areas of life, including mental and physical wellbeing. In this article, we take a closer look at the situation of trans people, who - due to experiences with discrimination and marginalization as well as their specific health-related interests - could be characterized by a particular vulnerability. METHODS: Using an online cross-sectional survey, which we designed collaboratively with experts from the trans community, we investigated the mental and physical health of trans people from German-speaking countries and their access to trans-related healthcare during the COVID­19 pandemic in the period from 1 May 2020 to 31 January 2021. RESULTS: Since the beginning of the COVID­19 pandemic, trans people have experienced barriers in access to gender-affirming treatments, mental health services, and COVID­19-related medical care. At the same time, trans people reported being affected by chronic diseases disproportionately more often than the general population, including those leading to a higher risk for poorer outcomes of a COVID­19 infection. Moreover, the participants reported being exposed to many risk factors associated with higher mental distress (e.g., having a chronic illness, belonging to a minority based on a non-heterosexual orientation, or having a low income). DISCUSSION: The results of this survey indicate that prior vulnerabilities with regards to health problems and the restricted access to an informed and qualified transgender healthcare were exacerbated by the COVID­19 pandemic.

Effects of the COVID19 Pandemic on Transgender and Gender Non-Conforming Adolescents' Mental Health.

We assessed the effects of the COVID19 lockdown on the mental health of transgender and gender non-conforming (TGN) youth (n = 18) vs cisgender youth (29 males; 29 females). Coronavirus Health Impact Survey (CRISIS) and Emotion Regulation Questionnaire were used in an online study. No group differences were found in demographic variables and exposure to COVID19. Negative emotions/feeling increased for all groups. Cisgender youth reported using more adaptive emotion regulation strategies than TGN youth. While the lockdown similarly affected TGN and cisgender youth, the former showed elevated levels of symptomatology and fewer adaptive emotional regulation strategies.