Transgender and gender diverse individuals face lower follow-up rates after psychiatric hospitalization

Transgender and gender diverse individuals who were hospitalized for psychiatric care were less likely to have a follow-up visit compared to the general population, suggesting they face transphobia in the hospital system. 

In a new study from ICES and the Centre for Addiction and Mental Health (CAMH), findings demonstrate that transgender and gender diverse (TGD) people face an interesting paradox: they have lower access to appropriate mental health care and support following a psychiatric hospitalization, yet have better follow-up after an emergency department (ED) visit. According to Statistics Canada, TGD people account for 0.33% of the Canadian population, with many living in large urban centres. 

Follow-up after an emergency department visit or hospitalization for mental health concerns is vital for people's long-term well-being. It's a risky time for folks, and we wanted to better understand if this population is being well supported after a mental health crisis." 

Dr. June Lam, lead author, associate scientist at CAMH and ICES Fellow

The researchers analyzed health data at ICES for all adults discharged from the emergency department (ED) or hospital for psychiatric care between 2012 and 2018 in Ontario, Canada. The study included 728 TGD and over 581,708 individuals in the general population. 

TGD individuals were identified through electronic health records from four primary care and hospital-based clinics specialized in working with this population. The data were then linked (anonymously) to hospital-based databases. 

Key findings 

• Compared to the general population, TGD individuals were younger, and more likely to live in underserved urban areas and low-income neighbourhoods. They also had much greater prior psychiatric care service use. 

• 55% of TGD individuals had outpatient mental health-related physician follow-up in the 30 days after discharge from the ED, compared to 38% for the general population. 

• One-third of TGD individuals had a follow-up with a psychiatrist within one month of an ED visit, about double the rate of the general population. 

• In contrast, TGD people were less likely to receive follow-up after a hospitalization. 

• Even after accounting for other factors, TGD individuals were still 21% more likely to have a follow-up after discharge from the ED than the general population, but they were 20% less likely to have follow-up after a hospitalization. 

"Lower follow-up after hospitalization is concerning because it suggests that there is something about the hospital experience that may be leading to avoidance of care after discharge," says Lam, who is also a psychiatrist in the CAMH Gender Identity Clinic. "Patients may be experience misgendering and transphobia in the hospital setting, which could influence whether they'll seek follow-up care." 

Improving the hospital experience 

The authors suggest that one way to improve hospital care for TGD patients is to ask for their chosen name, gender identity and pronouns on the initial intake form, and make sure that all care providers are using the correct name and pronouns throughout the care experience. 

Another approach is to tailor follow-up resources for TGD patients that address social determinants of health. Resources have been developed in the CAMH ED to provide TGD-specific crisis lines, housing resources, and community organizations. 

"Lack of social supports is often a perpetuating factor for mental health challenges for TGD people, so connecting them with community organizations that offer healthcare provider and peer connections is so crucial for TGD people's wellness and recovery long-term," says co-author Dr. Juveria Zaheer, a scientist with the Institute for Mental Health Policy Research and General Adult Psychiatry and Health Systems Division at CAMH. 

One limitation of the study is that it didn't capture nonphysician mental health care and there was no measure of need for follow-up. However, a higher rate of post-ED follow-up suggests that there is a greater need among TGD individuals, and standards of care recommend that follow-up should occur regardless. 

"These findings underscore the urgent need to improve hospital experiences and make sure that all patients feel safe and supported in seeking care. By addressing barriers such as a lack of social support, misgendering and transphobia in hospital settings, we can help close this gap and create a more equitable mental health system," says senior author Dr. Paul Kurdyak, a senior scientist with ICES and CAMH.