A lot can happen in 10 years. For Alex Keuroghlian, MD, MPH (any pronouns), the last decade has certainly been a busy, productive, and significant one, not just for the field of mental health but the psychiatrist’s own professional development and work in gender-affirming care for transgender and gender diverse people.

The Associate Chief of the Psychiatry Department at Massachusetts General Hospital presented the keynote address at ADAA’s 2024 annual conference which focused on sex and gender and depression and anxiety disorders in transgender and gender diverse populations. Ten years after Dr. Keuroghlian participated in ADAA’s Career Development Leadership Program (the CDLP award) in Chicago, the Associate Professor of Psychiatry at Harvard Medical School took to the ADAA stage in Boston to stress the importance of gender-affirming mental healthcare.

A Decade of Education, Advocacy, and Hard Work

From 2014 to 2024, Dr. Keuroghlian has worked endlessly and passionately to highlight and advance the state of mental healthcare for LGBTQIA+ youth and adults. In that time, he admits he wasn’t as active in ADAA as he would have liked to have been, but he was delighted to be the keynote speaker in his hometown and professional environment.

“It was a full circle moment a decade later to go from psychiatry resident to being asked to give the keynote,” he told ADAA. “It was a great honor and special to see so many mentors and colleagues in the audience. And it was a momentous thing for me 10 years ago to receive that award (CDLP) and attend the conference then.”

Lucky for ADAA that Dr. Keuroghlian made time for the conference and an interview, as busy and involved as he is in so many different initiatives, educational and advocacy organizations, and professional endeavors. As the Director of the Division of Education and Training Programs at the Fenway Institute, Dr. Keuroghlian also carves out time to ensure the public gets correct, scientific, evidence-based information in the field of mental health, particularly on gender related issues.

“I spend a lot of time trying to contribute to the public discourse through the media,” he explained. “It’s important for academic medical centers, institutions and their representatives to set the record straight with well-rounded perspectives that are rooted in clinical experience to counteract a lot of the narratives that aren’t reality based.”

The Reality of Transgender and Gender Diverse (Mental) Health

Being transgender is not a mental health problem, says Dr. Keuroghlian, in the same way that being cisgender is not a mental health issue. Rather it is society and political agendas that create the mental health issues in many circumstances, he explains. Human gender diversity has always existed across history, cultures, and countries, he adds, pointing out that it was just that medical innovations and discoveries like isolating sex hormones and synthesizing them or surgical advances finally came along to allow things that weren’t possible or acceptable before. “The medical options weren’t previously a reality, and expectations are changing now,” said Dr. Keuroghlian. 

“It’s not a mental health problem for someone, at any age, to be transgender or gender diverse. Gender identity emerges as young as two years of age. As early as three-years-old a child may express it clearly and adamantly and persistently.”

Studies Dr. Keuroghlian and his colleagues have done show that gender-affirming approaches to care do improve mental health outcomes. When gender-affirming care is initiated in all aspects of healthcare and wellness, including social, psychological, medical, and surgical, mental health problems like anxiety, depression, and substance use disorders improve dramatically, the psychiatrist told ADAA. He added that contrary to a lot of disinformation, there is no medical or surgical intervention for young children and that pubertal suppressant therapy, for example, is safe and already widely used for other medical needs.

“My talk (at the conference) was about how we can tailor existing evidence-based mental health interventions and practices using a ‘gender minority stress framework’ to improve the quality of care and health outcomes for these populations,” Dr. Keuroghlian said. “The gender minority stress framework explains why people may experience more anxiety and depression due to chronic developmental stigma and discrimination that they encounter their whole lives.”

Practicing Gender-Affirming Care, Not “Watchful Waiting”

Social gender affirmation before age 10 or even in the teenage years is associated with just as good mental health in adults as not being socially affirmed until adulthood, says Dr. Keuroghlian. He says there is no evidence to support the idea of “watchful waiting”- the belief that children and adolescents cannot possibly know what their gender identity is at such a young age.

“In the same way that we don’t tell a five-year-old cisgender boy or girl that they’re confused about their gender, we shouldn’t be saying that to transgender and gender diverse children either,” said the psychiatrist. “And when it comes to adolescents, every kid needs to go through puberty but a puberty that aligns with a person’s gender identity.” 

The process for determining medical and psychological, if needed, care for transgender and gender diverse youth is a very careful, collective, and thoughtful decision, noted Dr. Keuroghlian. Even in a state like Massachusetts with some of the most progressive laws on gender identity, there is a process that includes expert clinicians, practitioners, and family members. It is currently not possible, he says, without every parent or guardian in the picture agreeing to it. 

Providing culturally responsive gender-affirming care, as opposed to it being specialty care which creates bottlenecks and restricts how many practitioners can do the work, is especially important, says the former CDLP winner in 2014 and ADAA keynote speaker in 2024. In those 10 years, the Harvard psychiatrist has made huge strides in gender-affirming mental healthcare and ADAA is certain Dr. Keuroghlian will contribute to and see more inclusive, safe, and welcoming mental healthcare environments over the next decade. 

“It’s essential that every doctor, clinician, therapist, nurse practitioner, medical professional, etc., is confident and skilled in this type of care,” he said. “We all have to do our part to improve, enhance and modernize the healthcare system to support gender-affirming care.”