How to Provide Affirming Psychiatric Care to LGBTQ Teens in Transition

In this video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down with Jessi Gold, MD, MS, an assistant professor in the department of psychiatry at Washington University School of Medicine in St. Louis, and Amanda Calhoun, MD, MPH, a psychiatry resident at the Yale Child Study Center in New Haven, Connecticut, to discuss how to best support adolescents questioning their identity, or in transition, and how to model good behavior for the parents of patients.

Click here to view part 1, part 2, and part 3 of this conversation about the state of child and adolescent mental health.

The following is a transcript of their remarks:

Faust: Teens making transitions in terms of sexual orientation, sexual preference, and how, again, sort of the two sides of this.

On one hand, it feels like, when I was growing up, mostly people just kept that all to themselves, and they suffered in silence with difficult questions that would not be so difficult if they could just have someone to talk to or realize that that's normal. On the other hand, people may feel pressure to sort of live your truth, live out loud, almost before you're ready to.

How do you approach that, Dr. Calhoun? Guiding someone through a difficult transition, not necessarily gender transition, but just transition in terms of this normative role or labeling that they were given and who they really think they are.

Calhoun: Yeah. I think it's a complex journey, because it's a different journey for every child. And I always take a cue from the child and I'll tell parents, "Let your child guide you."

So if your child is asking you questions about why they were born a boy or why they were born a girl, talk to them about that. It rarely is helpful to say, "Oh, let's not talk about this," because if your child is bringing it up, you want to create an environment in which the child is able to talk as they're understanding their identity. I think that one of our friends, Dr. Turban, talks about this a lot. But gender-affirming care has so many positives, and so I think now with legislation and everything that's going on, it's very, very upsetting for a lot of my kids who I see.

I think the most important thing, the most damaging thing, I have seen in children who identify as queer or transgender or whatever it may be, is lack of support from their loved ones. I would say their loved ones, whether they "understand" their journey or not, should be present as people who love them and are there to support them.

I try to be a source of support and say, "Hey, let's talk about this. What have you been thinking about? What have you been struggling with? What do you feel certain about? Let's talk about it." And with caretakers, talking about the fact that, sure, teens grow, they change, people grow and they change, but that doesn't mean that we shouldn't be present and understanding at every step of their journey and that we should jump to conclusions about how someone else should identify.

I tell my kids, you should identify however you want to and if you change that, good for you, I'm going to be here to respect you and support you either way. I think that is very powerful given that there are so many messages that tell them otherwise, "You must act this way. You must act that way. You can't do this. You can't do that." I think saying, "Hey, as long as you're not hurting yourself or hurting others, let's explore this. Let's talk about it," I think is really, really important.

I try to serve as a very positive source of support and really try to help children to feel comfortable and safe talking to me about things. Letting them know that if they change their mind tomorrow and they decide they actually want their pronouns to be this, I'm like, OK, just let me know so I can get it right, and then we keep it moving. I've found that that's been very, very helpful for not just the children, but the parents too.

Modeling how do you be a source of support, and the fact that you don't have to understand someone else's experience exactly to be supportive for them, right? I think that's been something that I've really, really worked on myself and me doing and really letting the children guide me, "What can I do to support you more? What do you want to talk about? What feels safe for you and right for you right now?" As opposed to me saying, "We're going to talk about this. I want to know this." It's sort of like, what would you like me to know?

Gold: Yeah, brain development-wise, adolescents and college-aged kids are often doing a lot of identity development, a lot of social development, and they're supposed to ask questions. Maybe we didn't ask them all out loud before and they're asking them more loudly and proudly and uncomfortably than they were before, but we certainly experiment on all things, right? It's always been a time for that.

I want to echo that if you turn to someone -- friends or family, which are going to be the first source of support for all of this -- when someone tells you something, even if you want to react, try not to. Because you can cause another trauma by telling them something that was actually supportive in your head, but was really hurtful to them. And they might not tell someone else for a very long time or won't feel safe doing that. So realize that listening is a super powerful skill.

The reason people get annoyed with therapists and psychiatrists is we often echo back what people say and we don't tell you what to do. You just want us to give you skills and tell you exactly how to fix something. Most of the time we're just asking questions to get you to figure out what it is you want to do. I forget that that's powerful, just as much as medication.

A lot of times over COVID, I thought, "I can't fix COVID. These people are miserable. I can't make them go back to college. They're stuck at home, so how can I help them?" And my personal therapist was like, "Jessie, is that all you do? Drug people better?" And I was like, "You're right. I actually am helpful just being someone people can talk to when they couldn't otherwise." There's a lot of power in that.

I think it's important that friends and family own that as much as they can, and we have to educate ourselves just as much as anybody else. There are only, what, 4% or 5% black psychiatrists in the country? The likelihood that you're going to get someone whose identity matches yours is quite small. I cannot be someone who doesn't understand how racism affects your mental health. [If so,] I'm not doing my job correctly. Very similarly, in a world where you're a parent, you have to understand this stuff to be able to support your kids.

Faust: I'm thinking about what medicine looked like 100 years ago, 50 years ago, 25 years ago, 10 years ago. I'm going to close this out by saying that people watching this probably are looking at the two of you and saying, "That's not Dr. Freud on the couch in Vienna, these are real people." That's a really good thing.

I think to me -- we talked about teen mental health and social media -- but at the end of the day, I am a little bit of a bear on it. I think [social media] is good because it brings people closer to the idea that the help that they need is available and it's available from people who resemble them intellectually or biographically or some way. It's not something that's far off or fancy with people on couches and beyond.

Gold: Yeah, 100 years ago, psychiatrists wouldn't have even wanted to talk to you about anything because they were just reflecting you completely. That's useless, in my opinion.

Really both of us, and I know Amanda well because she's a mentee and I've known her for a very long time, but both of us do this so that you know psychiatrists aren't those people anymore. We're not scary and we're not all from One Flew Over the Cuckoo's Nest or whatever you saw that terrified you about our job.

Being able to do these things with you guys, to be able to go on TV, to be able to have social media is really for us to say that the field is different and changing and we want to change. Let us help you and feel safe coming to us. Don't worry that we're just going to lock you up and drug you to sleep.

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