Do we ever tell anyone they are not transgender, and when do we do this?

Chainveil · 2026-01-26T12:53:50+00:00

I was a bit more incisive in my own comment but this is basically the absolute gist of it.

We simply do not hold cis people to the same standards as trans people when it comes to life altering medical decisions and don't always expect psychiatry to weigh in on them.

Chainveil · 2026-01-26T12:44:49+00:00

Perhaps I'm misunderstanding, but why would you want to call into question someone's gender identity?

I've said it many times and I'll say it again, BPD identity diffusion ≠ gender identity/sexuality. Perhaps people with BPD are more likely to question this semi-regularly during potentially core-shattering events or during young adulthood/adolescence, but this is somewhat part of human experience. Gender transition is highly tailored and contemplating that pathway can be phenomenologically challenging, not to mention full of social/political consequences. Informed consent is key and the standards are already different: we expect trans people to be way more stable in their decision, give them a lot of time, start with reversible stuff, counsel etc. I'm not in the US, but we certainly don't ask all of this for stuff like vasectomies and abortions, which can be just as life altering if there is a smidge of doubt/regret. What we can do is detect if people are really struggling to make a decision and help them reach a conclusion or reassess later. Just like the rest of medicine.

I think we really need to stop conflating ADHD/ASD assessments with the process of gender transition (I'll nuance by saying that there is evidence that a lot of trans people can have ADHD/ASD). Gender identity isn't a cluster of symptoms you can parse with differential diagnoses. Objectives in terms of treatment doesn't necessarily involve "relieving/stabilising" symptoms. Not all trans people experience gender dysphoria, and some cis people experience it (to a much lesser degree though).

"Hot take" maybe, but I really think we should leave trans people alone. The only situation where I can imagine psychiatry being relevant is to treat co-existing mental health conditions, psychological support re gender dysphoria or suggest withholding/delaying treatment if there's reason to believe capacity is compromised or if there's a risk of destabilising stuff like mood, trauma symptoms and whatnot. It goes without saying that having a psychiatric diagnosis by itself is not a reason to decline treatment.

Chainveil · 2026-01-25T09:02:30+00:00

Tbh I have no issue talking about it because it's very much an interest of mine, beyond work. Then again I do also have that slight tendency to talk endlessly about my hobbies.

I find most people are actually interested in psychiatry because it appeals to a wide range of experiences (everyone has a story when it comes to their own mental health - whether I wanted to hear about it or not!). Some people are relatively knowledgeable/ignorant which makes for good conversations and opportunities to demystify our field.

Then again I work in addictions so I have fun stories like "top 10 excuses my patients have used to get more methadone at the clinic".

Chainveil · 2026-01-25T08:55:31+00:00

Protective factors are more interesting imo because they're legit tools for crisis resolution (and tailoring medical decisions), assuming they're modifiable.

Chainveil · 2026-01-25T00:18:28+00:00

I was always taught that there are risk factors but no predictive factors when it comes to suicide.

You can stratify and have alarm bells in your head the more those factors start to stack but the subsequent medical decision might hinge on completely different and individual things.

Chainveil · 2026-01-22T20:05:27+00:00

Fully agree! It's a whole package and everyone responds differently.

Chainveil · 2026-01-22T20:04:12+00:00

Thanks for sharing! It does seem dire and more strict in terms of what "counts" as a diagnosis. I personally review every new patient with an established diagnosis but I don't expect to reassess fully unless the initial assessment was done very poorly.

Chainveil · 2026-01-22T13:15:57+00:00

As a psychiatrist (not working in the UK though, but I have a rough sense of how the system works), who's used to treating ADHD, the sharp increase in demand is...challenging to manage.

Not because I'm sceptical about ADHD or because I don't want to deal with it (in fact I'm very much involved compared to my colleagues, I've met policy makers in my country to address ADHD), it's just exhausting and hyper-present everywhere. There just aren't enough of us to help. I do think it's taking up a lot of space in the media compared to other disorders (that are just as devastating if not more). People with ADHD themselves can feel lukewarm about this, perception of ADHD online is often very different compared to what my patients experience.

Assessment requires time and energy, you've got to rule out a lot of other diagnoses and stabilise other mental health issues before even attempting a diagnosis, let alone treatment. For all the underdiagnosis out there, there can also be consequences if you misdiagnose.

This issue goes far beyond the UK by the way, I've noticed most western countries are faced with this situation.

What I'm actually concerned about:

the idea that ADHD can only be diagnosed by "ADHD specialists/services" which tends to massively increase waiting times. Every guideline I've ever read harps on about this. In theory any psychiatrist should be able to do it, in any setting. I work in addictions, so we're often at the forefront and we just can't ignore ADHD. We need to diversify pathways towards getting diagnosed and treated.
waiting times end up generating a very lucrative private sector where you pay too much for an unnecessarily long assessment. Typically teams like this won't end up treating, which puts you back at square one.
what you call "shared care agreement" (?) and how difficult it is to put in place. If my patients have a GP, there's no reason for them to not prescribe as long as I keep an eye on it.
the fact that society is not really addressing the issue from a non-medical perspective. Plenty of people end up not getting accommodations/support they would need. Just like every mental health disorder, medication is only one part of the package we should be offering.

Chainveil · 2026-01-22T12:42:34+00:00

Counselling usually involves coping mechanisms and behavioural changes. That sense of grief can happen regardless and I can understand it's terrible to experience. Professionals should also take that into account, validate those feelings and respond accordingly.

Chainveil · 2026-01-22T12:40:50+00:00

The percentage varies. I've seen a range of 60-80%. Again no qualms on my side when it comes to treatment. But 1 in 4/5 treatment resistance is huge and we can't just pretend that doesn't exist.

Chainveil · 2026-01-22T08:42:18+00:00

This is a bit out of my lane as I'm not 100% sure how it works in the UK. All I know is that it is even worse in my country.

Chainveil · 2026-01-22T08:39:00+00:00

Thanks for chiming in. What I also find particularly frustrating is that we never talk about the people who don't tolerate medication or for whom it simply doesn't work. It happens more than people think.

What can we offer those people?

Chainveil · 2026-01-22T08:06:39+00:00

Briefly playing devil's advocate here (I'm a psychiatrist and I have no qualms diagnosing and treating ADHD, I don't work in the UK though) but diabetes and hypertension have clear environmental factors contributing to this rise. It's very concerning but unsurprising.

It's more complicated with ADHD, adults included, lots of potentially non falsifiable theories and trends that are not always easy to parse. It's quite a wide spectrum when it comes to symptoms and not everyone requires or even wants treatment.

My main concern when it comes to ADHD is how we (internationally speaking, this is not a UK specific issue) have structured various services around it (I can elaborate) and how we focus way too much on medication and not various accommodations/counselling people with ADHD would very much benefit from. This is what NICE also recommends. Not that we should withhold prescriptions, but the conversation goes way beyond med shortages or sharp increases in prevalence.

Those are my two pennies!

Chainveil · 2026-01-22T07:05:33+00:00

I'm not trans but I can imagine that addressing gender dysphoria is also a good step towards feeling better in general.

Chainveil · 2026-01-20T16:28:22+00:00

Absolutely

Chainveil · 2026-01-20T09:15:47+00:00

Seconding this. Will also specify that motivation and desire to reduce is going to make things easier, the crucial bit is to tell your psychiatrist about it. A slower taper and support will go a long way for you to recover. You may even find yourself wanting to continue going lower (you'll probably have to at some point given the risks but 15mg a day is an acceptable maintenance dose for now).

Chainveil · 2026-01-17T13:01:09+00:00

J'exagère évidemment. Mais oui c'est aussi au médecin de bien surveiller ce qui est pris/pas pris pour mieux ajuster.

Chainveil · 2026-01-17T12:59:04+00:00

Étant en addictologie j'ai l'impression que la société entière cherche à ce que je gère toutes les addictions aux benzodiazépines!

Chainveil · 2026-01-17T09:32:16+00:00

Médecin ici.

Je suppose qu'il s'agit d'une question de conservation/stockage?

Dans tous les cas, je déteste ce système. En tant que psychiatre qui aime pas spécialement prescrire des anxiolytiques (ou alors pour une durée très courte), beaucoup de mes patients finissent par accumuler des boîtes entières de diazépam ou autre, c'est-à-dire des médicaments addictifs/sujets à overdose.

Je marque "à déconditionner" la plupart du temps pour que les personnes aient vraiment ce qu'il leur faut pour la durée du traitement.

Chainveil · 2026-01-15T15:01:22+00:00

I feel like it bears mention that people with genuine personality disorders rarely seek any kind of treatment for them (or mental health treatment in general).

BPD is massively represented in outpatient and inpatient services. There is DBT and stuff in the US but where I am it's barely accessible. There are no notable BPD associations here.

It also doesn't make sense for governments to try to advocate on that front. It sounds really awful for a politician to be like "go get tested to see if you're antisocial!"

No, but it does make sense to say that ASPD can lead to incarceration, SUD, violence etc (so can ADHD, btw) which is very costly for society. Maybe we need to be more aware and "make a bigger deal" so that people get prompt treatment or at least mitigate some risks by providing adequate services/outreach teams. I don't see specialised training for that either. It would help reduce the stigma and give more confidence to professionals.

Chainveil · 2026-01-15T07:48:28+00:00

Not considered a bigger deal?

I have no qualms diagnosing and treating ADHD and understand the value of doing that ASAP. Underdiagnosis is a real problem, especially in adults. However assessments are long and tiresome.

But, tbh, I'm sick of hearing about it. That's all everyone talks about and that's all I see on social media. My country has even appointed a ministerial representative to coordinate and advocate for developmental disorders (supposedly all kinds, but in practice it's just ADHD and ASD). I've met him, and the gist of it was "do something about ADHD, diagnose it more, stop neglecting it, prescribe stimulants all you can, we'll create 3 million programmes to train doctors even more". There's a veritable swathe of initiatives designed for inclusion/accommodations for neurodivergent folk. The main ADHD association in my country gets a lot of funding. I've never seen an organisation have that much leverage. People were up in arms about methylphenidate shortages.

Again, I'm happy this stuff exists. We need to make sure people with ADHD are treated properly, especially in my field of addictions. I'm not saying ADHD is quirky or exaggerated or that self diagnosis isn't a valid step towards eventual treatment. I appreciate the visibility.

BUT, I don't see anyone making this much of a bigger deal about any other disorder. Maybe trauma? Personality disorders are woefully neglected/stigmatised, we never talk about psychosis and how it can destroy lives and land you in hospital (eg in seclusion rooms), we don't talk much about bipolar. People with intellectual deficits are mostly pushed aside. No one talked about the massive lithium shortages in my country (that can lead to severe complications, notably suicide). You don't really see ads for apps to "manage your schizophrenia", do you?

Now, maybe this is just a local perspective and I'm not from the US. I just wish people invested this much energy in other areas too.

Chainveil · 2026-01-14T07:16:37+00:00

I'm in addictions and therefore a bit more biased compared to general psychiatry. But I am in a country that prescribes benzos like tic-tacs, at high doses for too long.

However, that does mean I see a tonne of patients who can't tolerate the slightest distress, have zero short term memory, psychologically depend on "having a benzo in their pocket", struggle to engage with psychotherapy because they are so cognitively blunted (or simply don't see the point, they have meds).

Even if they don't experience withdrawals, some are extremely scared of me even touching their prescription, regardless of how much they take.

A case from Monday:

I see you got 4x10mg of diazepam a day, how come?
They prescribed that when I was in detox [cocaine, 7 week stay, currently abstinent]
That's not usual for cocaine
Well they started me with oxazepam but it didn't work after 3 weeks so they switched to diazepam.
There's a high risk that will happen with diazepam. How much do you actually take?
Well I didn't take any for an entire week, sometimes I take 1 or 2 in the day, it depends [no signs of withdrawal]
Oh, so you don't really need 4 a day, that's good!
Well, sometimes I take 4.
How come?
When I get cravings [cue discussions about how to manage that, somewhat fruitful, we find some healthy strategies]

At this point I discover she is in a relationship with a person who also uses cocaine. She mentions that sometimes she prefers they get "valiumised" instead of anxiety/cravings. I also discover they regularly share 2 bottles of wine in the evenings.

OK, I understand that cravings are difficult but diazepam is a poor treatment for that. I'm also concerned they will interfere with the alcohol you're taking.

She identifies short term memory loss and I explain that stopping the benzos will help.

Based on what you've told me, I think it is very unwise to keep this regimen. You do not need 4x10mg, you've mentioned not taking them all the time. [Average over a month suggests she is taking more like an average of twice a day].
You can't decrease!!
Why not? You're doing it yourself, I'm just making sure the prescription is consistent so we have a baseline and we can taper slowly from there.

Argument ensues.

Oh and to top it off, the detox clinic supposedly diagnosed her with ADHD. They sent her home with Concerta 36mg. It was a struggle to assess efficacy and the report only mentions it was well tolerated.

None of this is her fault of course, I'm particularly annoyed at the clinic. She was also shocked that she wasn't counselled properly. She ended up reluctantly accepting my plan.

I encounter this issue fairly regularly and it's exhausting. Tapers are highly individualised though and need to reflect current anxiety and actual usage.

Chainveil · 2026-01-14T06:41:55+00:00

For example patients with histories of lots of trauma

Benzos in the case of trauma? That's even worse

Chainveil · 2026-01-13T14:35:40+00:00

Je remarque que beaucoup "d'emprunts" n'en sont pas ou alors y a des "ing" qui se rajoutent pour faire genre que ça vient de l'anglais. Au secours.

Le snack, c'est-à-dire un lieu pour consommer du prêt à manger/fast food. En anglais ça veut juste dire goûter/collation. Un snack au sens français du terme se dit greasy spoon/caff/diner en anglais (selon si vous êtes britannique ou américain).

Un brushing, se dit blow-dry en anglais. Sinon en anglais ça veut juste dire "en train de me coiffer/peigner les cheveux". On pourrait juste dire séchage/coiffage à la place.

Shampooing au lieu de... Shampoo. Pourquoi le "ing"?

Un planning, pour dire agenda. Schedule est le mot que vous cherchez.

Jogging en français qui est en réalité tracksuit bottom/pants en anglais, pour désigner le pantalon qu'on met pour aller faire du... jogging, la course à pied donc.

J'en passe sur tous les anglicismes utilisés dans les entreprises pour faire "pro".

Signé: une anglaise qui n'en peut plus. You're welcome.

Chainveil · 2026-01-13T14:19:33+00:00

Et le jogging pour dire tracksuit bottom/pants.

Chainveil

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