WASHINGTON—U.S. Senator Chris Murphy (D-Conn.), a member of the U.S. Senate Health, Education, Labor and Pensions Committee, sent a letter urging the Department of Health and Human Services’ Behavioral Health Coordinating Council (BHCC) to take steps to address an unmet need in caring for transgender and gender expansive youth by providing guidance for best practices for inpatient mental health care. This comes after Murphy heard from Connecticut health care providers about the issue.

U.S. Senators Jeff Merkley (D-Ore.), Ben Ray Luján (D-N.M.), Sherrod Brown (D-Ohio), Tammy Baldwin (D-Wis.), Tina Smith (D-Minn.), and Richard Blumenthal (D-Conn.) also signed the letter.

“Nationally, adolescent mental health providers have expressed concern for the increasing need for adolescent behavioral health services. We have also heard from health care providers about the need to answer an urgent call for the unmet mental health needs for transgender and gender expansive (TGE) adolescents, including exploring, non-binary, agender, genderfluid and queer youth,” the senators wrote. “Our goal is to help mental health providers offer the best care they can to the nation’s TGE youth without a delay in treatment.”

The senators continued: “While behavioral health and pediatric organizations have published resources regarding TGE health care, we have heard from hospital providers they are seeking guidance on best practices for serving gender diverse youth in community residential and inpatient mental health settings. Reports addressing gender-affirming care largely focus on care beginning at the front desk, the importance of educating staff, congruent documentation practices in electronic medical records, understanding terminology, pronoun usage, and acknowledging patients by their chosen names and not their given or legal names whenever possible.”

“As the BHCC works to bring together leadership across the Department to provide more equitable behavioral health care, we ask that you consider ways to improve and communicate best practices for inpatient and residential mental health care for boarding adolescent TGE youth. Importantly, we ask you include the voices of these youth at the table,” the senators concluded.

The full text of the letter is available here and below:

Dear Assistant Secretaries Levine and Delphin-Rittmon,

Nationally, adolescent mental health providers have expressed concern for the increasing need for adolescent behavioral health services. We have also heard from health care providers about the need to answer an urgent call for the unmet mental health needs for transgender and gender expansive (TGE) adolescents, including exploring, non-binary, agender, genderfluid and queer youth. As co-chairs, we encourage the Behavioral Health Coordinating Council (BHCC), along with experts in the field of adolescent transgender care, to offer guidance on best practices for adolescent inpatient mental health care for these youth. Our goal is to help mental health providers offer the best care they can to the nation’s TGE youth without a delay in treatment. The focus of this request is for the pressing needs of hospital or residential care even as we recognize the need for guidance across all settings of mental health care.

The Trevor Project released the National Survey of LGBTQ Youth Mental Health and noted alarming data that more than half of transgender and non-binary youth seriously contemplated killing themselves in 2020. The survey participants were diverse: 45 percent youth of color and 38 percent identifying as transgender or non-binary. There was variation in the rates of suicide attempts across youth depending on participants’ race and culture, with 12 percent for white youth compared to 31 percent for Native/Indigenous youth, 21 percent for Black youth, 21 percent for multiracial youth, 18 percent for Latinx youth, and 12 percent for Asian Pacific Islander youth.

While behavioral health and pediatric organizations have published resources regarding TGE health care, we have heard from hospital providers they are seeking guidance on best practices for serving gender diverse youth in community residential and inpatient mental health settings. Reports addressing gender-affirming care largely focus on care beginning at the front desk, the importance of educating staff, congruent documentation practices in electronic medical records, understanding terminology, pronoun usage, and acknowledging patients by their chosen names and not their given or legal names whenever possible. There is a dearth of guidance relative to boarding TGE adolescent patients for inpatient or community-based residential mental health care. As a result, providers report delays in psychiatric emergency departments while administrators explore where to place TGE youth needing inpatient care due to questions such as who might be an appropriate roommate and what restroom a patient should use.

Approximately 2 percent of youth identify as transgender.  In the United States, over 1.9 million youth are estimated to be LGBT between 13-17 years of age, with almost 150,000 self-identifying as transgender. TGE youth may experience a host of mental health burdens including anxiety, depression, and suicidal thoughts, largely due to societal stigma and lack of access to care. Transgender youth  who are 15 and older can be particularly vulnerable, and would benefit from specialized support beyond their mental health needs.  They experience homelessness, unemployment, poverty, uninsured status, and physical and verbal abuse at higher rates than cisgender individuals. The need for guidelines for inpatient, residential care, and specialty care is essential for TGE youth to receive equal treatment and access to care. Alongside this is the opportunity to improve the quality of patient data collected, including sexual orientation and gender identity data, so that health providers, researchers, and advocates can better understand the prevalence of and need for mental health care for TGE youth.

There are examples of the federal government providing such guidance. The Substance Abuse and Mental Health Services Administration promulgated guidelines for organizations treating substance abuse for LGBT individuals. Also, regulations for youth experiencing homelessness includes provisions for best practices, including respectfully asking all youth to identify their gender on forms, including terms such as transgender, and to assign housing based on gender identity. Lastly, the Office of Refugee Resettlement provides guidance for unaccompanied children and requires providers to consider gender self-identification for housing placements.

As the BHCC works to bring together leadership across the Department to provide more equitable behavioral health care, we ask that you consider ways to improve and communicate best practices for inpatient and residential mental health care for boarding adolescent TGE youth. Importantly, we ask you include the voices of these youth at the table.

Thank you for your consideration.

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