"I don't think I have been out of fight or flight. Ever." transgender people's experiences in inpatient psychiatric treatment.

Background: Historically, marginalized groups have been deemed unwell and deserving of correction, resulting in disproportionate use of inpatient psychiatric institutionalization. Despite changes over the last hundred years, individuals from marginalized groups continue to experience poor treatment in inpatient psychiatric settings. Transgender people are marginalized in a society where it is assumed that all individuals exist solely as woman or man with predetermined roles influenced by innate biology based on their sex assigned at birth, i.e. gender essentialism. This contributes to mental health disparities (e.g., depression, anxiety, suicidal thoughts, and suicide attempts), which may result in higher acuity symptoms, leading to overrepresentation in inpatient psychiatric settings. Yet, little is known about transgender people's experiences during inpatient psychiatric treatment.

Objective: To describe the experiences of transgender people in inpatient psychiatric treatment.

Design: A qualitative descriptive study.

Setting: Interviews were held in person or over Zoom.

Participants: Adults who self-identified as transgender and had been admitted to inpatient psychiatric treatment during the last five years were recruited to participate through community organizations, social media, and word of mouth.

Methods: Semi-structured interviews were conducted between March 2019 and June 2022. Data were analyzed using thematic analysis.

Results: Participants (N = 15) described experiences within inpatient psychiatric treatment. The first theme, gender essentialism causes stigmatizing experiences through structural and enacted power, was characterized by deliberate or accidental misgendering, gender treated as irrelevant to care, pathologized gender diversity, and withholding of gender-affirming needs. The second theme, psychological and emotional strain as the price paid for enforced gender essentialism, included examples of drained emotional resources, powerlessness, and worsening of gender dysphoria. Lastly, the theme actions in disruption of the structural gender essentialist power illustrated how the gender essentialist systems in place can be interrupted and resisted by transgender patients and healthcare professionals.

Conclusions: Power structures are embedded in psychiatric hospital policies and practices, as well as the physical layout of the hospital, operating under the assumption that all patients are either man or woman based on their sex assigned at birth. Healthcare professionals may unintentionally or deliberately reinforce these structures, further marginalizing transgender patients. Healthcare professionals have the opportunity to disrupt these harmful systems by advocating for and implementing changes that challenge gender essentialism. Creating care environments that incorporate gender diversity allows transgender individuals to focus on their mental health and recovery, rather than expending emotional resources navigating a system that overlooks or invalidates their identities.

Social Media Abstract: Inpatient psychiatric treatment reinforces gender essentialism, subjecting transgender patients to stigma and mistreatment. Participants described experiences of frequent misgendering, dismissal of gender-affirming needs, and emotional strain from navigating a system designed for non-transgender patients, leading to worse mental health symptoms, including gender dysphoria, and feelings of powerlessness. Healthcare professionals reinforce these harmful systems deliberately or unintentionally. However, instances of disruption by healthcare professionals and transgender participants were observed leading to the creation of affirming experiences despite the prevailing gender essentialism. Future opportunities to disrupt these structures include advocating for systemic change, engaging in patient-centered care, and developing inclusive policies. By creating inpatient psychiatric environments that accommodate gender diversity, healthcare providers could allow transgender patients to focus on their mental health and recovery, rather than combating stigma. Inclusive care can shift the focus from navigating systemic transphobia to healing.