Inside Transgender Psychiatry and Psychosomatic Medicine

Session 203

Dr. Hansel Arroyo is a transgender psychiatry and psychosomatic medicine physician and fellowship director at Mount Sinai. He talks about his journey to transgender psychiatry, what he loves about it, how he made a fellowship for it, and so much more. Join us to learn about this unique specialty!

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[01:09] Interest in Transgender Psychiatry

Hansel became interested in psychiatry very early on at the beginning of high school. He was drawn to understanding human behavior and what made people feel that way they felt or react the way they reacted.

Fast forward to medical school and adult psychiatry residency, he didn’t know how many specialties there are in the field of psychiatry and how you can tailor the world of being a psychiatrist into something that fits your interest. For him, it was working with people with chronic medical conditions and people in disadvantaged positions, particularly like either racial minorities and sexual minorities.

During residency, he focused on working with Hispanics, and providing care for patients who didn’t necessarily have access to mental health care. In the community that he was working in New York City, there was particularly many who were undocumented and didn’t speak Spanish. And it was really hard for them to get access to mental health services.

He worked a lot with them developing programs to improve access to care. This got him excited to improve access to other communities he was interested in, particularly the LGBT community. Then he started working with people living with HIV, which led to him working with people with trans experience.

After residency, Hansel went to a fellowship in Consultation-Liaison Psychiatry, previously known as Psychosomatic Medicine. He focused on caring for people living with HIV, and then branched into trans people. Then five years ago, they opened up the Center for Transgender Medicine and Surgery.

'You can find whatever it is out there that you're passionate about and, and create that opportunity for yourself.'Click To Tweet

[06:15] Traits That Make a Great Transgender Psychiatrist

Hansel says that you have to have the heart for the community. Because the relationship between mental health and the trans community has historically not been a positive one.

'Historically, the trans community has had a lot of barriers to medical care in general, and then on top of that, mental health care.' Click To Tweet

Initially, for trans people in America to either get access to hormone therapy, or to get access to surgeries, they are forced to see a psychologist or psychiatrist for a certain period.

Then after a year of you trying to convince a psychologist or psychologist that you were trans, then you were allowed to get hormones. Then you have to spend another chunk of time being in “therapy” so you can get access to surgery.

And so, it was timely and costly. A lot of trans folks still have that mentality that it’s what mental health services look like for trans people. And so first, as their doctor, you have to be aware of that history and to have an open heart.

[08:45] The Biggest Myths or Misconceptions About Transgender Psychiatry

'Transgender Psychiatry in the way that we see it now is very new.'Click To Tweet

Hansel says the Transgender Psychiatry fellowship that he created was the first one in the nation and it’s four years old now.

There was never a dedicated group of people doing this sort of work. There were definitely silos around the United States to providers that would specialize in it. But there wasn’t a cohesive way of approaching it.

Even if you think of research and published work, in the 90s there were less than five articles being published a year. That number has increased over the years. But still, there wasn’t a lot of information out there.

[10:23] Typical Day

Hansel works in an outpatient setting and has a very structured day, which he loves. He’s working outside of the hospital doing scheduled visits. It’s a clean nine to five job where you see patients for an hour. Then follow-ups could take 20 to 30 minutes.

And psychotherapy usually takes 45 minutes. They do a variety of different things at the clinic. Patients can come in just to see you once, if they are interested in a surgical procedure.

Hansel explains that the guidelines require that patients be in therapy for a period of time, at some point, a year, before they could get access to gender affirming treatments. Now, those guidelines have changed, and that is no longer the requirement.

There are also patients they see longitudinally. These are people who have may have mental illness, and they want to address their mental illness with them.

[12:48] Taking Calls

Having a mental health provider available in the emergency room is something that they’re trying to do at his hospital. They want to include an educational component to all levels of providers in trans health.

'There was this study that came out of looking at how much time is dedicated in residency and medical school in transgender health and it came out to be less than four hours.”Click To Tweet

Sadly, there isn’t much awareness in trans health both in medical school and residency. So they’re trying to make sure that providers who are not specialized in this have at least a base of knowledge. So if you are a trans individual going to the emergency room, you know that you’re going to be meeting somebody who’s culturally competent and who knows how to address your needs.

Your primary care doctor should also have enough knowledge to be able to care for you and to care for those needs as well because it’s not that complex. And this is something Hansel hopes for in the future.

[17:13] The Training Path

Applicants usually have to have completed the four-year adult psychiatry residency program. They have the option for those who are in their PGY-4 to come in and do the fellowship during that time if their residency allows.

[20:32] Message to Future Primary Care Physicians

'There has to be some cultural competency when you are interacting with trans folks.'Click To Tweet

Hansel explains they see higher rates of discrimination, higher rates of depression, anxiety, of trauma. And that is going to be a big part of their care when you’re seeing a patient who may not have the best compliance with their treatment. So you also have to be able to address the other layers of who the person is.

Hansel underscores the importance of having a tuned mentality to know that there are this other social dynamics of rejection and discrimination that are playing along. For instance, if you misgender somebody that comes into your office, that may trigger a lot of trauma and PTSD.

Unfortunately, there are higher rates of suicide in the trans community than the general population. And that goes up to almost eight times higher than the general population. So having that kind of sensibility is key and to be able to refer to mental health services when red flags come up.

[23:34] Specialties They’re Working the Closest With

Hansel works closely with primary care endocrinologists. He adds that they designed the clinic in a way that they have all services located in one place.

Oftentimes, the patients go to their primary care doctor, and then they get referred to a therapist at another location which is scheduled for the next appointment after several weeks. And patients can get lost in the middle of that.

So Hansel says they structured their clinic in away that they are all in the same location. And this has improved access to care as well as compliance to care.

[25:06] The Most and Least Liked Things

Hansel loves meeting people, seeing and hearing their stories.

'Psychiatry can be very beautiful because people get better, and it's not necessarily immediate.'Click To Tweet

He mentions that this is not the type of field for you if you want immediate gratification and you want to see somebody get better in a few days. But if you want to see somebody progress throughout their lives, then this is the field for you. In a way, it’s a way to measure medical progress in a non medical way. And he loves getting to know people to that level.

On the contrary, the least thing he likes is the administrative stuff, especially dealing with insurance companies.

[27:12] Final Words of Wisdom

If he had to do it all over again, Hansel would still be in transgender psychiatry. If you’re interested in transgender medicine or transgender psychiatry, Hansel recommends getting involved with local LGBT, either clinics or programs.

And if you’re not limited in residency yet or you’re thinking about going to medical school and you have a heart for the community, just look into your local city or town. See if there’s any LGBT support groups or free clinics. That’s a great place to be exposed to learn and to feed that interest.