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Topic: 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?
