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- [00:01]
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It's 1979. Johns Hopkins has banned gender affirming surgery, and similar clinics are closing their doors. But investigations into the biological origins of gender identity are about to change all that. Welcome to the Carlat Psychiatry Podcast, Keeping psychiatry honest since 2003.
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I'm Chris Aiken, the editor in chief of the Carlit Psychiatry Report.
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And I'm Kelly Newsom, a psychiatric NP and a dedicated reader of every issue. We'll start with a preview of the CME quiz. You can earn CME through the link in the show notes and stay tuned to the end to find the answer to this question. For which condition did lavender oil show efficacy in a recent large randomized controlled trial? A Major depressive disorder b Post traumatic stress disorder c c Primary insomnia D Premenstrual dysphoric disorder. DSM 5 defines gender dysphoria as marked incongruence between the gender a person was assigned at birth and the gender they experience on the inside. That sounds straightforward, but there are two consequential ideas in there. The DSM is saying that we aren't born male or female. We are assigned those genders, and sometimes the assignment is wrong. The idea traces back to intersex conditions, where people are born with ambiguous genitalia. In the past, physicians assigned a gender at birth and performed surgery within the first few days to reshape the genitals accordingly. This was standard practice in the 1950s, and it wasn't rooted in ideology it was rooted in a theory. The prevailing view at the time was that gender is determined by the environment. Babies were born gender neutral and would comfortably develop into whatever gender they were assigned. In most cases, that assignment was female because constructing a vagina is easier and less risky than constructing a functional penis. This started to change in the 1990s as evidence accumulated that gender identity takes shape before birth. Influenced by genetics and androgenic spirit exposure in the womb, people who had been assigned an arbitrary gender at birth began requesting reassignment surgery in large numbers, complaining of widespread stigmatization, body image problems, and impaired sexual functioning. So we've shifted from a 1950s model in which gender is entirely malleable to a more nuanced view that recognizes the role of biology and hormones in shaping gender identity. But at no point in that trajectory did medicine hold that gender was a fixed binary concept. Nor did the ancient Greeks, Shakespeare or Judaism and Islam has long recognized intersex genders as muqanathun. As for Christianity, Paul discards early notions of gender and ethnicity, just as he does for the kosher diet in his letter to the Galatians, There is neither Jew nor Gentile, male nor female, for you are all one in Christ Jesus.
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Building on that biological understanding, the standards for intersex care changed officially in 2006, with landmark guidelines urging surgeons to wait before assigning a baby's gender. Unless surgery was necessary for physical functioning, it was deferred, and that's how practice is today. We allow time for the child's gender to develop. The family is involved in the decision, guided by a multidisciplinary team. The belated surgery comes with more physical risks, but it is psychologically safer. Before 2006, most intersex patients were assigned female, but today, most elect the more difficult male surgery. The reason is more biological than cultural. Most of these cases involve androgen insensitivity syndrome, where the brain may still respond to the circulating androgens, even if the genitalia don't develop fully.
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We've also seen a shift toward male transitions among people with gender dysphoria, but likely for different reasons. Twenty years ago, most patients transitioned from male to female, two to three times more common than the reverse. Today, the rates are equal, and among younger patients, it's shifting the other way, with more girls identifying as boys. Why? No one knows, and we don't want to add to the speculation.
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DSM 5 removed the word disorder from gender dysphoria. This was a controversial step back in 2013. You know, if gender dysphoria is not a psychiatric disorder, then what is it doing in the dsm? The DSM committee almost removed the condition entirely, but they kept it in, as one member of the committee told me, largely to ensure insurance coverage for transgender care. ICD11 takes a more consistent approach, placing gender dysphoria under sexual health rather than under psychiatric disorders. In 2014, another change happened that accelerated gender affirming care. The Affordable Care act prohibited gender discrimination by health insurers, including discrimination based on gender identity. And as coverage expanded, more clinics opened, including a new center for Transgender Health at Johns Hopkins, four decades after they closed their original clinic.
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Along the way, we've moved from a model where psychiatrists act as gatekeepers, deciding who is mentally fit to undergo these procedures, to one where informed consent is the deciding factor. But as the recent malpractice lawsuits have shown, that shift carries its own risks. If you work in this area, follow the WPATH guidelines and document them clearly. They were Last updated in 2022, and each addition has eased the gatekeeping requirements. Here's a summary of what they require for hormonal or surgical a clear diagnosis of gender dysphoria, capacity to make a fully informed decision and consent to treatment an assessment of social supports and any comorbid medical or psychiatric conditions and if other conditions are present, they should be reasonably well controlled. The guidelines also require patients to live publicly in their new gender role and and take hormones for at least a year before surgery, though for some surgeries they've lowered the requirement to six months. Hormones, however, can be started without a prior trial period of living in the new role. That's a brief summary. If you're going to do an assessment, Google WPATH to get the full set of standards.
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When you do these assessments, make sure the patient has a good understanding of the surgery, what's involved, and that they're not motivated to do it purely by a psychiatric disorder that isn't treated. I'll give an example, changing some of the details of a patient that I once turned down for gender transition surgery. This was a 35 year old woman who developed psychotic depression after the death of her long term partner who was also a woman. Now the patient I saw viewed herself as the man in the relationship and she believed that as she transitioned into a man, she would somehow be reunited with with her deceased love. Hormones and surgery carry risks the changes brought by hormones are partially reversible, while surgery is not. Hormonal therapy can cause a potentially permanent loss of fertility. Both estrogen and testosterone carry risks of blood clots and stroke. Testosterone can also cause bone mineral loss, elevated cholesterol, hypertension and diabetes. The long term risks of hormonal therapy are not clear, but cancer is a possibility. Careful documentation at every step isn't just good practice in the current climate, it's essential protection.
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We've tried to steer clear of ideology in this podcast and follow the evidence where it leads us. We focused on current controversies, but in doing that we've left out a lot. Gender affirming care isn't just about hormones and surgery. It's about accepting people's identity and valuing who they are. Transgender people face misunderstanding, marginalization and stigma, sometimes violently and always at a cost to their mental health. Over their lifetimes, 50% experience suicidal ideation, 50% engage in self harm and a third make a suicide attempt.
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If you're listening to this podcast and having thoughts that life is not worth living, help is available. Dial 988 to find a provider near you.
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For today's research update, we're pulling a classic from 2024. It examines a new use for lavender oil S', Alexan, which is sold over the counter in the US as carmade. This is a regulated extract approved in Europe for generalized anxiety disorder with glutamatergic, serotonergic and neuroprotective properties. This trial tested lavender oil in mild to moderate major depression, comparing it head to head against sertraline and placebo in 498adults. The lead author is Siegfried Casper, whose industry funded team has produced most of the lavender research and the dearth of independent replication is a meaningful imitation. Prior trials established lavender's benefits in anxious depression. This is the first to test it in pure depression.
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In this study, both of the active treatments Sertraline and Lavender beat placebo response and remission rates for sertraline 50 milligrams a day and lavender 80 milligrams a day were nearly identical. Lavender, however, edged ahead on functional outcomes and tolerability. Its main side effect was burping in about 17% of patients. Annoying but not dangerous One note on
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dosing this study used 80 milligrams daily, but most anxiety trials show better results at 80 milligrams twice daily. The bottom line Lavender oil has a role in depression. Consider it when patients have high levels of anxiety, prefer natural treatments or do not tolerate antidepressants. Though it is prescription only in some countries, it's available over the counter in the US's Calm Aid. Get more research updates on Dr. Akin's daily psych feed. Search Chris Akin MD on LinkedIn, Twitter, Facebook, Blue sky and Threads.
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Are you struggling to tell Borderline from bipolar? I speak with Dr. Mark Zimmerman, who led some of the pivotal trials in this area in the May issue of the Carlat Report. Get $30 off your first year subscription with the promo code podcast in all caps. The Carlat Report has operated free of industry funding since it began in 2000.