Social Determinants of Health

 

Case Scenario:

Susan is a 68-year-old woman who presents with her husband after being referred to your clinic by her endocrinologist for concerns of worsening anxiety. She tells you that her anxiety started 6 months ago after she began transitioning from male to female and started hormone therapy. Her anxiety often occurs in social events such as dining out, due to fear of being scrutinized by others. For example, she talks about a lunch she had last week with her son and daughter-in-law when she sensed a marked fear of rejection. She states, “I felt like everyone was staring at me. I was afraid they’d judge me.” Before she began her transition, Susan was a runner, she enjoyed going to the movies, and she loved visiting new restaurants. Now, as a result of the worsening fears of anxiety, she now rarely leaves her home.

You learn that Susan was assigned male at birth and identifies as a transwoman and that her sexual orientation is heterosexual. You learn that 1 year prior to her decision to fully transition, she intermittently wore women’s clothing and presented in public as a woman. Susan grew up in a strict religious household and was the youngest of five boys. She always had a sense of being female, and secretly identified as such, but lived most of her life as a man. She married a woman and had two children, then eventually divorced and later met a man whom she married. At the age of 65 years old, Susan developed the courage to came out as a transwoman.

Susan now sees an endocrinologist who prescribes her hormone therapy to feminize her secondary sex characteristics. She tells you that when she looks back at her childhood, she always knew that she was a girl from the age of 4 years old. “It was my very first conviction, the first thing I grew certain of as a young person, that I was a girl,” she says. But given that the world told her that she was male, assigned her male sex at birth, and expected her to be masculine, it was easier to live her life as a male. As a result, she had a strong desire to be rid of her masculine secondary sex characteristics. Living her life as a man for many years resulted in marital conflict, ultimately in divorce, and rejection by her religious siblings and daughter.

Susan expresses dissatisfaction with her chest, saying “I’d feel better about my breasts if I had implants.” Her husband tells you that she is “fixated” on mastoplasty. Even though Susan reports having an intense fear of rejection, no persecutory delusions are elicited, and she denies having auditory or visual hallucinations.

Susan shares that for the last 6 months, she has been worrying about negative evaluations and rejection by others for being transgender. You explore this further and learn that her anxiety is related only to social situations in which she may be judged for being transgender. She denies having periods of being tremulous or short of breath, or having chest pain, fear of dying, or other panic symptoms. She also denies having generalized worries in other areas of her life, such as finances or her relationships with her husband and friends, who are accepting of her gender identity. She abstains from alcohol (her last drink was 20 years ago) and denies past or present use of illicit drugs.

What is the difference between gender identity and sexual orientation?
What is the possible differential diagnosis for Susan?
As a PMHNP, what cultural considerations will you consider when working with transgender patients?
What are the social determinants of health that can affect a patient’s mental health?
What are the possible mental illnesses that can be comorbid with anxiety in transgender clients?
What is gender dysphoria? How is it different from body dysmorphic disorder?
In your role as a PMHNP, how will you promote rapport and trust when working with transgender clients?

 

Sample Question

Understanding Gender Identity, Sexual Orientation, and Susan’s Case

Gender Identity vs. Sexual Orientation

  • Gender Identity: A person’s internal sense of being male, female, both, or neither.
  • Sexual Orientation: A person’s enduring pattern of attraction to others, based on sex and gender.

In Susan’s case, her gender identity is female, while her sexual orientation is heterosexual.

Differential Diagnosis

Considering Susan’s symptoms, the most likely diagnosis is Social Anxiety Disorder (SAD). SAD is characterized by intense fear and avoidance of social situations, often stemming from a fear of negative evaluation or rejection.  

Other potential diagnoses, though less likely given her specific symptoms, include:

  • Generalized Anxiety Disorder (GAD): While GAD involves excessive worry about various aspects of life, Susan’s anxiety seems primarily focused on social situations.
  • Specific Phobia: This diagnosis could be considered if Susan’s anxiety was limited to a specific social situation, such as public speaking. However, her anxiety seems to be more generalized.

Cultural Considerations for Transgender Patients

  • Stigma and Discrimination: Transgender individuals often face significant stigma and discrimination, which can impact their mental health.  
  • Cultural Sensitivity: Understanding the cultural context of the patient’s gender identity and any specific cultural factors that may influence their experiences.
  • Affirmative Care: Providing affirming and non-judgmental care can help build trust and improve treatment outcomes.

Social Determinants of Health and Mental Health

Social determinants of health, such as socioeconomic status, education, and access to healthcare, can significantly impact mental health. For transgender individuals, factors like discrimination, stigma, and lack of access to gender-affirming care can exacerbate mental health challenges.  

Comorbid Mental Health Conditions

Transgender individuals may be at increased risk for certain mental health conditions, including:

  • Depression: Feelings of sadness, hopelessness, and worthlessness.
  • Anxiety Disorders: Excessive worry and fear, including generalized anxiety disorder, panic disorder, and social anxiety disorder.  
  • Substance Abuse: Use of alcohol or drugs to cope with stress and negative emotions.
  • Suicidal Ideation: Thoughts of suicide or suicide attempts.

Gender Dysphoria vs. Body Dysmorphic Disorder

  • Gender Dysphoria: A marked incongruence between one’s experienced gender and assigned gender. It involves a strong desire to change one’s physical sex characteristics.
  • Body Dysmorphic Disorder: A mental health condition characterized by excessive preoccupation with perceived flaws in one’s appearance.

While both conditions involve concerns about physical appearance, gender dysphoria is rooted in a deep-seated incongruence between one’s gender identity and physical sex characteristics.

Promoting Rapport and Trust with Transgender Clients

  • Active Listening: Give full attention to the patient’s concerns and feelings.
  • Empathy: Show empathy and understanding for the patient’s experiences.
  • Respectful Language: Use gender-affirming language and pronouns.
  • Avoid Assumptions: Avoid making assumptions about the patient’s gender identity or sexual orientation.
  • Educate Yourself: Stay informed about transgender issues and best practices for providing culturally competent care.

By addressing these factors, mental health professionals can provide effective and compassionate care to transgender individuals.

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