A transgender refugee woman experiencing posttraumatic stress disorder symptoms and homelessness

• Transgender individuals experience high rates of violence, discrimination and homelessness.

• Psychiatric disorders should be managed before or concurrent with medical transition for gender dysphoria.

• Posttraumatic stress disorder (PTSD) can be a psychiatric comorbidity for transgender individuals who frequently experience recurrent trauma; intersectional oppression and social determinants of health need to be addressed for adequate treatment of PTSD.

• Addressing homelessness and other social determinants of health requires long-term engagement with interdisciplinary team support.

• Access to medical transition has been associated with significantly reduced suicidality.

A 23-year-old transgender woman was referred to a community health centre and presented with a long history of gender dysphoria and desire to medically transition. She disclosed an extensive history of trauma and that she had experienced recurrent nightmares, insomnia, hypervigilance, depressive symptoms, dissociative symptoms and social isolation. The patient was a recent refugee claimant, born and raised in Saudi Arabia. She had minimal English proficiency and was residing in an emergency shelter. She had difficulty accessing supportive health care and navigating the complex refugee system. She was eventually connected with the clinic and through interpretation services was able to tell her story.

The patient had identified as transgender at an early age. On discovering that she was transgender, her father attempted to murder her. She managed to escape and was subsequently apprehended by law enforcement officers, and reported being sexually assaulted by them. Once released, the patient continued to be harassed on a daily basis by people on the street and in her neighbourhood, from name-calling to being beaten to having her long hair shaved off by a mob. With her friends’ support, she immigrated to Toronto, where she struggled to navigate the complex social service and health care systems because of language barriers, cultural differences, homelessness and poverty.

Over multiple visits to her physician at the community health centre, the patient disclosed more about herself, including that being born with male genitalia had caused her substantial distress since childhood and that puberty was especially difficult because of increased facial and body hair growth, deepening of her voice and penile erections. She shared her desire to live as a woman and described expressing her gender identity through feminine clothing, makeup and jewellery. She disclosed that she had experienced passive suicidal ideation and hopelessness for many years. Gender dysphoria was diagnosed.

The patient underwent a physical examination and baseline screening blood tests, with normal findings. Because she requested and met readiness criteria for initiating hormone therapy, her physician prescribed spironolactone 25 mg, an androgen blocker. Four weeks later, the patient reported some clinical benefit, including reduced facial hair, and no adverse effects. Spironolactone was increased to 50 mg, and estradiol was started at 1 mg. The patient returned for regular clinical follow-up and blood tests. Over a period of 6 months, spironolactone was increased to 100 mg twice daily and estradiol was increased to 3 mg twice daily, on the basis of a hormone therapy guideline from the Sherbourne Health Centre,1 the patient’s hormone levels and her desired effects. The patient experienced facial feminization, softening of skin, some breast development, decreased spontaneous erections, and reduction of facial and body hair; however, she continued to experience dysphoria about her genitals. After discussing transition-related surgical options (TRS, also known as gender-affirming surgery), she was referred for vaginoplasty.

While she underwent treatment for gender dysphoria, she was concurrently referred for a psychiatric evaluation, given her history of severe trauma and symptoms of mental illness. Posttraumatic stress disorder (PTSD) was diagnosed. In addition to weekly psychotherapy, she was prescribed mirtazapine 30 mg, taken at bedtime, for PTSD and insomnia, and prazosin 1 mg, taken at bedtime, for nightmares. The medication doses were gradually increased until she was stable at a dose of mirtazapine 60 mg and prazosin 6 mg. She reported improved sleep, reduced PTSD symptoms and suicidal thoughts, and feeling more hopeful about the future.

The care team integrated a social determinants of health–based approach into her treatment plan. She was referred to a housing worker to assist her in securing long-term stable housing. Accessing housing was extremely challenging because of a lack of affordable housing in Toronto. She temporarily stayed in emergency shelters but had to leave because of continuous transphobic discrimination and harassment, which threatened her safety. The patient became a sex worker and exchanged sex for food and shelter; however, she experienced ongoing violence. She is currently on a wait list for subsidized housing.

She was referred to a transgender community-based drop-in program to encourage connection to community, but the language and cultural barriers prevented her from feeling that she belonged. This led to her case manager connecting her with an English-as-a-second-language school to improve proficiency in English. A lawyer helped the patient gain permanent resident status in Canada, and her care team completed forms to change her sex marker and name on her government-issued identification.

The patient is continuing to focus on addressing both the PTSD and gender dysphoria. Her symptoms and social situation led her to sometimes miss appointments and medication doses. Though her condition is improved, she continues to experience nightmares and difficulty trusting others. She has had to postpone pursuing vaginoplasty because her precarious housing situation currently precludes her from having a good aftercare plan. A highly regimented aftercare plan is required after vaginoplasty, which involves vaginal douching and dilation as often as 4 times per day, gradually decreasing in frequency over time. As with any surgery, there is a risk of wound infection, particularly after the vaginoplasty. Patients are at risk for vaginitis and urinary tract infections, especially if hygiene is not maintained. Lack of stable housing adds an extra challenge to ensure adherence to the postvaginoplasty protocol.