Complex psychiatric comorbidities in Thai trans women: A case series

Introduction

Compared to the cisgender population, transwomen (TW) are at higher risk of developing mental disorders, including anxiety and affective disorders, suicidality, and substance abuse (Schulman & Erickson-Schroth, 2019). Gender-affirming treatments could alleviate their distress but, even following gender transition, TW remain at greater risk of mental health issues (Jellestad et al., 2018). Stigmatization, both interpersonally and at a larger social level, is considered to be the leading cause of psychiatric disorders among TW (Verbeek et al., 2020). From a young age, TW often experience bullying and discrimination at school and have been prohibited from expressing their gender identity, such as through wearing feminine uniforms or hairstyles due to the Thai educational policy. Some TW discontinued their education as a result and practiced sex work due to lower educational level and discrimination (de Lind van Wijngaarden & Fongkaew, 2020).

Additionally, TW can suffer from gender dysphoria (GD) (Zucker et al., 2016). As well as being a consequence of gender incongruity, some psychiatric conditions could mask GD manifestation and interfere with diagnoses of GD. Gender identity development is affected by both biological and psychological factors (Steensma et al., 2013). Psychiatric disorders with biological or psychological origin can also influence identity formation and expression. Moreover, feelings of shame, which inhibit clients’ self-disclosure in order to avoid social discrimination, are more frequently found in Asian cultures compared to Western cultures (Bedford & Hwang, 2003). Therefore, fear of social rejection can prevent TW from disclosing their genuine gender identity to their peers or even family members (Huang et al., 2020). Providers in TW healthcare could find difficulties in complex psychiatric comorbidities and cultural considerations in diagnoses, treatment planning, gender-affirming therapy, and psychological interventions.

In this study, we portray the clinical experience of three TW with GD and psychiatric comorbidities at our Gender Health Clinic located in Bangkok, Thailand. All these clients were undergoing gender-affirming hormonal therapy (GAHT), which included regular hormonal prescription and pre-procedural psychological counselling. GD was diagnosed by a psychiatrist according to the DSM-5 criteria and psychiatric follow-ups were provided as appropriate. An initial evaluation was conducted to identify those who have contraindication for GAHT, such as active liver disease, hormone-responsive malignancy, or a history of venous thromboembolism. Clients with no contraindications would be prescribed with either transdermal or oral estrogen, and antiandrogen for TW with intact gonads. Clients would be monitored every three months to ensure the safety and efficacy of the treatment. Once their condition is stable, the visit would be every 6-12 months for holistic health surveillance. TW healthcare providers should recognize these patterns so that proper evaluation and holistic care can be delivered to our TW clients.

Cases

Conclusion

These case reports demonstrate complex psychiatric comorbidities with GD, which could be underrecognized and untreated. Our cases’ patterns might be common and beneficial in terms of early recognition. However, some limitations including cultural differences should be considered in our study’s generalizability.

In the context of Asian culture and tradition, Thai TW have experienced great internal stigmatization and social discrimination (de Lind van Wijngaarden & Fongkaew, 2020), which can result in secondary anxiety and delay the timing of identity disclosure and even their own identity recognition. Neurodevelopmental disorders often co-occur and interfere with gender identity development. Communication deficit among the patients could obscure diagnoses of GD and related conditions. Borderline personality disorder often relates to identity disturbance, including gender identity and sexual orientation. TW with borderline personality disorder represent the diversity of sex and gender due to their identity disturbance and highlight the factors that should be considered in treatment. Healthcare providers for TW should be aware of complex psychiatric comorbidities in order to prescribe holistic gender-affirming interventions. Appropriate psychiatric referral is recommended to promote broader physical and mental dimensions of healthcare for all TW.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of their clinical details was obtained from the clients.

Ethical approval

This report was exempted by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. (COE No.050/2021) Date of exemption: September 28, 2021.

Author contributions

Sorawit Wainipitapong: Conception and design of the study, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the completed article;

Soravit Burakitpachai: Acquisition of data, Analysis and interpretation of data, Drafting the article;

Thanapob Bumphenkiatikul: Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content.