I recently saw a male patient who identifies as female and has begun taking hormones (Premarin and progesterone) to switch genders. When I assessed this individual, she appeared to have cluster B traits and a very unstable personality.

What kind of screening is done when a person wants to change sex? Her extremely unfeminine mannerisms have created a number of difficulties for her among members of both sexes. Are there any useful interventions to help with this transition? — SUSAN HEMION, PMHNP, Bainbridge Island, Wash.

Providers should be aware of the Standards of Care (SOC) that outline a series of steps some transgender individuals take as they move forward with their transition. Note that these SOC are not legally mandated. Some of these steps include: (1) seeking counseling with a mental health professional/gender specialist; (2) creating a “real life” experience in which the person lives as their preferred gender for a certain amount of time (generally one to two years); (3) undergoing hormone replacement therapy; (4) completing sexual reassignment surgery or other surgeries to create congruency between an individual’s inner and outer sense of gender, if desired; and (5) collaborating with therapist and clinician to assess for readiness before beginning medical treatment and starting hormones (a letter is usually required) and to assess for readiness before undertaking surgery (a letter, psychiatric evaluation, and a “real life” test is usually required before sexual reassignment surgery will be performed).

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Hormones can have an impact on one’s emotional state. Many transgender people report feeling more at peace after they begin treatments, but hormones may also cause other fluctuations in mood that lead to depression or anxiety. Often, there is no notable difference in moods after beginning hormone treatments. Dosages should be monitored to prevent negative outcomes.

Regarding the patient described, cluster B traits are not developed from a gender-identity crisis. I’m curious if this patient has a psychotherapist she has been working with in treatment. Interventions that would typically be used for someone with a personality disorder should be employed with this individual.

A transgender support group, sensitive feedback about “unfeminine” presentation, and reinforcing self-care skills may be helpful. When working with transgender persons, explore ways of integrating the masculine and feminine principles/archetypes.

The World Professional Association for Transgender Health (www.wpath.org) offers detailed information on SOC for transgender persons. — Sharon Demeter, MSN, CNM, WHNP, assistant clinical professor, department of family health care nursing, University of California, San Francisco (152-10)