Transcription:
Northwestern Medicine's Gender Pathways Program

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Kaitlyn Kunstman. She's an instructor of Psychiatry and Behavioral Sciences at Northwestern Medicine, and she's here to highlight Northwestern Medicine's Gender Pathways program.

Dr. Kunstman, it's a pleasure to have you join us today. I'd like you to start by explaining a little bit about transgender care in this country, how it had typically been treated, how it's evolved, and where we are now.

Dr Kaitlyn Kuntsman: Absolutely. Thanks for having me. So, that's a very broad question, I think. And it's an exciting time for transgender care and gender-affirming care in general, as well as gender-affirming mental health in this country. I think as you can see, this is a hot topic in the media, in politics and in sort of the research that we're doing around gender-affirming care across the country. Historically, the mental health field has been set up as gatekeepers of gender-affirming medical and surgical care. This has been the case since the early to mid-1900s. And really historically, the phenomenon of gender diversity has been conceptualized as a mental health disorder, even included in our diagnostics and statistical manual, our DSM within psychiatry.

And so, we've been really set up as the gatekeepers of this care historically for decades. And I think it's very exciting as society at large better understands gender diversity as medical providers better understand gender diversity, we can see this gatekeeping role evolve into more of an informed consent model, the model of care that we use elsewhere within medicine.

And there's a lot of reasons for that. I think it's an exciting time. I think as we've moved away from a gatekeeping model of care, one that prioritizes the ethical principle of non-maleficence or do no harm, we're moving towards informed consent, prioritizing patient autonomy, better understanding the factors that go into gender diversity, which patients are able to access gender-affirming care, how do we best support them through accessing gender-affirming care? And I think Gender Pathways Program is uniquely set up to care for this patient population here in Chicago.

Melanie Cole (Host): I'm so glad you made those points and such a great topic we're discussing here today. So, tell us a little bit about Northwestern Medicine's Gender Pathways Program, how it came about. I mean, obviously, why you saw the need and why this is such an important program.

Dr Kaitlyn Kuntsman: Yeah. So, the Gender Pathways Program here at Northwestern Medicine is a multidisciplinary team, that includes providers from plastic surgery, urology, gynecology, endocrinology, primary care, our speech language pathologists, our primary care doctors, our social workers, and now our mental health psychiatry department.

The Gender Pathways Program was begun by one of our plastic surgeons, Dr. Sue Jordan, who's the medical director of the program around the summer of 2020. Over the last two years, psychiatry under my guidance and leadership first as a resident, now as a faculty member, liaisoned with the Gender Pathways Program to create our gender clinic within Psychiatry. And we work very closely with a wider program in a multidisciplinary way to provide gender-affirming mental healthcare to the wider patient population, and to provide consultation around pre-surgical readiness for patients seeking gender-affirming surgery.

Melanie Cole (Host): So then, tell us a little bit more about your role in this program and the services that you offer you just mentioned for the mental health aspect, which I imagine is so comprehensive, describe some of the highlights and features.

Dr Kaitlyn Kuntsman: So, my role within the Gender Pathways Program is to run our mental health gender clinic. And so, it's within the psychiatry department, our outpatient psychiatry department. We run a half day a week outpatient clinic. It's actually a resident-run clinic for multiple reasons. One being that we can see more patients with a two-resident model with myself as the supervisor. It also increases access to education and training for our trainees around gender-affirming care. And we additionally are very lucky to have medical students rotate with us at times as well, so there's an education piece to our clinic.

But really, what we're focusing on right now is providing an evaluation clinic for patients referred to us from the Gender Pathways Program or from the community who need pre-surgical mental health evaluations. And this is a holdover from this gatekeeping model of care that I referenced earlier where insurance companies require letters of readiness from mental health providers in order to cover gender-affirming care, specifically around surgery right now. And there's a huge need for those evaluations. There's a lot of barriers for trans and gender-diverse patients to access knowledgeable providers, providers who are willing to write these letters, willing to train in understanding the unique mental health needs around surgery, those sorts of things.

And so, our clinic right now is set up to see anywhere from one to four new evaluations a week for patients who are undergoing gender-affirming surgery, and to do a comprehensive mental health assessment, looking at a standard mental health assessment, what are the diagnoses or symptoms that might be bothering this person, medical care, social history, family history, substance use, all of those standard things. But in our evaluations, we're doing something a bit more unique and that we're exploring in an informed consent way what does this patient understand about the procedure they're seeking, the risks, the benefits, does it align with their goals for their body? Do they have an underlying diagnosis of gender incongruence? Meaning does their gender assigned at birth match with their gender identity? When those two are incongruent, we think about gender incongruence and understanding where are the areas of support that we can intervene on before surgery to help set them up for success in surgery and post-operative recovery.

And so, oftentimes we're doing a more extensive psychosocial history, looking at the social determinants of health that might be impacting this patient, what are their sources of support, what are the logistics around obtaining surgery. And we're doing contingency planning. So if there were to be a complication after surgery, how might that patient work through that and use the supports that they have at their disposal? And so, that's sort of a unique element that we're doing in these pre-surgical evaluations and one of the most helpful components that we can offer to our surgery colleagues, offer to the other treatment team members to help set this patient up for success.

Melanie Cole (Host): What important work you're doing, Dr. Kunstman. And can you discuss some of the ethical concerns with these type of evaluations and how evaluations and perceptions have changed over time and how you approach them with your team, the cultural shift that really has catapulted the need for these types of services?

Dr Kaitlyn Kuntsman: As I alluded to before, historically, this phenomenon of gender diversity has been conceptualized as a mental health disorder, and you can see that in the ways we've conceptualized this over time back in the early 1900s, things like transsexualism, which is a very outdated term. In DSM-IV, we talk about gender identity disorder, really highlighting the identity as being disordered, very pathologizing. In DSM-V, we talk about gender dysphoria. So, there's a shift away from the identity, towards the stress that the individual experiences. And now, more recently with our ICD-11 coding system, we talk more about gender incongruence, which really just focuses on the experience itself. And I see this as a shift away from pathologizing gender diversity, hopefully mirroring the increase in acceptance that we see across society at large, although we still have a long ways to go and I think really highlights the shift from gatekeeping care to allowing patients the autonomy to participate actively in their care like we do across all other areas of medicine, allowing patients to tell us their gender identity, accepting that gender identity, working with them to identify are there interventions and treatments that can help reduce their level of distress or the burden that they might have existing in their body at this time. Can treatments help reduce the burden of mental illness or symptoms, suicidal ideation, suicide attempts?

We know that gender-affirming care is lifesaving in these ways. It absolutely can help reduce the burden of mental health symptoms and illness and improved quality of life. And so, as we've moved away from a gatekeeping model of care, prioritizing non-maleficence or do no harm, this idea of why would we remove a part of your body if that's not necessary, well, we now know that it is necessary for some people and that it leads to significant improvements in quality of life to access gender-affirming care and surgery.

And so, I hope that over the next few decades we make even more strides towards prioritizing autonomy, prioritizing informed consent, and moving away from pathologizing differences in gender.

Melanie Cole (Host): Are there some barriers when you were setting up this program that you'd like to let other providers know that may be thinking about starting programs like this? Speak about any of those challenges, barriers, and how you overcame them.

Dr Kaitlyn Kuntsman: I think one of the big barriers to setting up a program like this and we were very lucky because the Gender Pathways Program at large over at Northwestern Medicine had been set up by the time that we began collaborating on a specific gender clinic within psychiatry. So, we were very lucky in that regard and the stars sort of aligned in that way, and we were very lucky that our program leadership, department leadership, were very supportive of carving out this space for this population.

And I think one of the biggest barriers is that there is such an overwhelming need for this care within the community; need for competent, knowledgeable mental health providers that want to work with trans and gender-diverse individuals and are knowledgeable and connected to programs like the Gender Pathways Program that provide comprehensive evidence-based, quality, gender-affirming care. And so, one of the big barriers we faced is we have a lot of need and a lot of need for just general mental health support therapy, medication management, support groups, insurance navigation, all of these really important components to providing quality care. And we really had to focus in on the area of biggest need within our department, so that was these pre-surgical evaluations.

So, we have limited availability within our department to provide mental health care to every single trans or gender-diverse individual who seeks out care through our program. And so oftentimes, we're working with community organizations, we're working with our psychology colleagues within the department. We're working with other community providers, therapists and psychiatrists to find other gender-affirming mental health options, so that patients who are looking to establish psychiatry care but don't necessarily need a pre-surgical evaluation are able to get linked to care.

Melanie Cole (Host): So, tell us a little bit about the gender clinic structure and the patient journey. What is that like? And for referring physicians who are meeting people from all of these communities, what would you like them to be able to tell their patients about the Pathways Program?

Dr Kaitlyn Kuntsman: So, our clinic is a resident-run clinic. So, we have two residents who see patients in parallel under my supervision, one half day a week on Friday afternoons. And we evaluate between one to four new intakes per week. And we also see patients for followup visits, 30 minute followup visits, as needed around surgery or for any active mental health concerns.

And the patient journey oftentimes starts with a referral directly from the Gender Pathways Program, either the surgeons, the surgery office, or the clinical coordinator for the Gender Pathways Program, Rebecca Sabri. And we've created an online screening form that patients are able to fill out online to request an appointment. It collects information like demographic information, pronouns, name, and any desired services the patient requests like a letter of readiness or they want psychiatric medication management or they want a therapist. And then, it briefly screens for mental health symptoms, so that we have a better understanding of what needs the patient might come in with at the time of the appointment. And so, we use this screening form to help direct patients to the best care. If they don't need a letter of readiness for a surgery, then we can direct them to our intake line or our therapy colleagues to get set up with the desired service.

Once patients are screened, our front desk intake staff call them and offer them an appointment in our clinic. Our wait list right now is usually between two to three months, and our appointments are two hours long to allow us time to do these in-depth assessments and evaluations. At the end of our evaluation, we're able to provide that patient with a letter pretty much immediately, unless there's concerns that we have to discuss amongst the team. And oftentimes, patients only see us that one visit. We have a very small handful of patients who elect to see us for ongoing care or that have ongoing active needs around the time of surgery where we'll provide additional support.

Melanie Cole (Host): Dr. Kunstman, as we wrap up, please speak a little bit about your team and this multidisciplinary approach because there are many teams in clinical areas involved. So, tell us a little bit about how they collaborate. And while you're doing that, please speak about the unique areas that set you apart, why it's so important to refer to the specialists at the Northwestern Medicine's Gender Pathways Program.

Dr Kaitlyn Kuntsman: Yeah. Our team is very, very large here at the Gender Pathways Program, and we collaborate monthly as a wider team to talk about innovations in the program, upcoming research, changes to this state of transgender gender-affirming care in general. And on a department level, we meet with the surgeons monthly to discuss challenging cases, patients who are coming up for surgery that are having maybe challenges or issues before surgery and to discuss patient outcomes. How did the patient go through surgery? Is there anything we should be monitoring for from a psychiatry or mental health perspective after surgery? And we work directly with the surgeons. We work directly with the coordinator; at times, working directly with the endocrinology teams and the primary care doctors who are seeing our patients. And the team approach is one of the reasons to consider referring to gender pathways program. It's rare to find these multidisciplinary programs that offer quality care to trans and gender-diverse patients. We're probably one of the biggest in Chicago. And with that team approach comes the ability to collaborate and to provide innovative ways to think about how do we take care of this unique patient population? How do we improve outcomes? How do we address barriers to care? And I think we're uniquely set up to answer those questions because of the size and diversity of our program.

Melanie Cole (Host): And you receive such excellent support from Northwestern Medicine. Thank you so much, Dr. Kunstman, for joining us today and telling us about this comprehensive program, as you say, for this very unique patient population. And thank you again for all the great work that you're doing. To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/psychiatry to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.