Trans + Past Adjustment Disorder = HIMS???

Here's the situation I'm in:

- first-time medical, going for 3rd class med, long term goal is to get Basic Med and continue under that indefinitely
- trans, a little under 5 years on hormones
- prior diagnosis of "adjustment disorder with anxiety" (subtype of adjustment disorder, coded 309.24, no anxiety diagnosis) - fits FAA criteria for automatic issuance: "stable, resolved, no associated disturbance of thought, no recurrent episodes, and psychotropic medication(s) used for less than 6 months and discontinued for at least 3 months"
- no current or prior use of psych medications or substance use
- no current mental health diagnoses

Essentially, if it weren't for the trans issue, this would have been an automatic issuance without even a deferral. Instead, for some reason, the FAA has come back demanding monitoring by both an LCSW/psychologist including quarterly face-to-face visits and counseling and HIMS sponsorship and monitoring involving "periodic face-to-face visits" and "other requirements of the HIMS AME" for a special issuance.

My aeromedical consultant was quite shocked by this as well.

Just polling out here for second opinions/options/recommendations/advice. If I go the SI route how long can I expect the monitoring to last (alternatively: how quickly should the cert expire so I can hop onto Basic Med)? What should I expect from the HIMS visit?

Also, any pilot-friendly HIMS recommendations for Northern California would be appreciated.

Thanks

 

Also, to clarify - there are only two routes, either do what the FAA says or get a denied medical. That second isn’t the end of the world, you can reapply later.

But I am curious what the justification was for requiring monitoring. I think the trouble is, you fell into block B, less than 5 years on hormone treatment + history of preexisting mental health concern - waiting a few months and the AME could have issued. I’m just a big dumb airman, but what I find curious is why the requirement for HIMS, because that isn't the FAA’s guidance on this. Their direction requires a psychiatrist evaluation and report of hormone stability. Does it say HIMS (substance dependence program) or evaluation by a HIMS psychiatrist?

https://www.faa.gov/about/office_or...me/guide/app_process/exam_tech/item48/amd/gd/

my read is that it’s a one time evaluation, not ongoing monitoring. But honestly, this is the first time I’ve heard this question.

 

Blowback from German wings?

https://pubmed.ncbi.nlm.nih.gov/30009750/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317390/#!po=33.7500

 

I think they may have changed that guideline recently - I recall seeing them change it a few months ago so that Block A criteria were a bunch of ANDs that included no prior mental health diagnoses, which is why I decided to bite the bullet and do it instead of running out the clock on the 5 year timeframe. I guess they changed it back.

"You will need to engage with a HIMS AME for sponsorship and commencement of a monitoring program... Periodic face-to-face visits with the HIMS AME"

 

Side comment - FAA is spending time to change language to be appear to be more inclusive. I wish they would instead shift that effort to modernize their practice and actually become more inclusive.

 

How about we do both?

 

Trying to appear more inclusive doesn't necessarily result in being more inclusive. Becoming more inclusive includes and/or will result in appearing more inclusive. So, I agree with spending the time and effort to become more inclusive if you want to appear more inclusive, not just studying how to look like it.

 

Sorry I misread your post and thought you said you wanted to focus on other things rather than inclusivity (aka a common bad faith complaint made by people who don’t want to become more inclusive). Apologies and I agree with what you said. What I get for reading stuff before my morning coffee.

 

Been there, done that, more times than I want to admit...

 

I thought about it this weekend and then got curious, which usually means I'm about to learn something.

All of the monthly updates to the AME guide are here: U (faa.gov) The only updates I saw were:

6/24/2020 - In Item 48, General Systemic, Gender Dysphoria, Revised Gender Dysphoria Mental Health Status Report to clarify issue/defer criteria.
9/25/2019 - In Item 48. General Systemic, Gender Dysphoria, updated the FAA Gender Dysphoria Mental Health Status Report to remove use of the word “form.
7/09/2019 - In Item Exam Techniques, Item 48. General Systemic, Gender Dysphoria, updated link to World Professional Association for Transgender Health (WPATH) guidelines. (Note: Link must be opened in Google Chrome.)
1/27/2016 - In Item, 41., G -U System, Gender Identity Disorder, rename to Gender Dysphoria, update information, and relocate entry to Item 48, General Systemic, Gender Dysphoria.
1/27/2016 - In Item 48., General Systemic, Gender Dysphoria, add Gender Dysphoria Mental Health Status Report form.

So nothing significant has changed recently.

I never recommend a lawyer for medical issues - they just don't work. But it might be appropriate here to question why there is a SI requirements for recurring quarterly psychiatric appointments when that isn't a criteria in the AME guide. The psychiatrist may need multiple appointments to make the determinations required for the status report, but that should be on the psychiatrist to decide, not a bureaucrat in the FAA.

Now, I'm not an expert and there might be a rational explanation, but I don't understand where the SI requirement came from.

 

Maybe it came from the much higher suicide rates?

I understand why this condition would warrant additional monitoring, unlike other issues discussed here, going over thousands of cases people with this condition it reads like there is a dramatically higher mention of the word “suicide”

From my understanding, if your vision is not ideal and you don’t like wearing glasses, you can choose to wear glasses for flight, if you drink you can choose not to drink before a flight, however if you suffer from gender dysphoria I don’t think you can choose to not have gender dysphoria before a flight.

Still would be ideal if this persons psychologist could make that call and put their license on it instead of someone who never laid eyes on the pilot and has no skin in the game at the faa

 

Yes and that's why there is a psychiatric evaluation required. But for the FAA to require a constant and ongoing evaluation for the duration of the SI is not supported anywhere that I can find. In fact it runs contrary to the defined standard.

 

How so?

I didn’t see where it said people who have gender dysphoria don’t have suicidal thoughts after a certain amount of years, the poster did admit to having this condition.

Hard to support all the other very wide cast net of things the FAA wants to monitor, including people who have no diagnosed medical condition, and not be ok with monitoring a diagnosed and chronic mental disorder that sees a very high suicide rate. Unless I’m missing something here?

 

I like this website, gets me to look up things I wouldn’t have thought to

Seems if the poster wanted to avoid all this, they could have got their sport certificate, drivers license medical, the hours count just the same, wait out the last year of their 5 years from the start of trans, which is some pointless non science backed number, and then convert to a full on private and get a in office 3rd class, let it expire and go basic.

If I read those regulations correctly.

 

Because it goes against the narrative. It’s proven trans have a higher suicidal rate and a higher rate of abused drugs/alcohol.

 

I don't believe she said that. Am I missing it? As far as I can see, you're the only one in this thread talking about suicide.

You are correct about sport pilot, but the cow is way out of the barn now.

 

Thought it was horse out of barn?? Eh

I read the comment about suicidal rate being higher with a trans person. Ok - if true, I can see it warranting a closer look. But I would say the closer look has already been done. Thus - not sure why the continued monitoring.

 

My house backs up to a cow pasture. They're on my mind.

Suicide is not a part of this person's case. That was introduced by someone here, not by the OP.

 

It’s the major concerning part of the condition of gender dysphoria, which is directly linked to the posters case.

“ An ex-post facto study with a sample of 151 people who were clients at the unit, 97 in the male to female trans group, 54 female to male. Clinical evaluations were carried out assessing variables of suicidal ideation and attempts, along with a possible psychiatric diagnosis.

Results: Almost half (48.3%) reported suicidal ideation, 23.8% had attempted suicide.

Conclusions: There are higher levels of suicidal ideation and suicide attempts in people with gender dysphoria than in the general population. No differences were seen between groups in terms of gender/sex. Psychiatric morbidity was not an influential variable for suicidal behaviour. This suggests that suicidal ideation is one of the best indicators of the risk of suicidal behaviours.”

“The current study investigated the suicide death risk in the largest clinical cohort of gender‐referred individuals to the Center of Expertise on Gender Dysphoria at the Amsterdam UMC, the Netherlands, between 1972 and 2017. Findings from the chart reviews showed us a decrease in suicide death risk over time in trans women and no change in suicide death risk in trans men. Trans women, however, showed a higher suicide death risk than trans men. Between 2013 and 2017, the suicide risk in Dutch referred transgender people (40 per 100 000 person years) showed to be three to four times higher than the general Dutch population”

“Prevalence of suicide attempts, self-injurious behaviors, and associated psychosocial factors were examined in a clinical sample of transgender (TG) adolescents and emerging adults (n = 96). Twenty-seven (30.3%) TG youth reported a history of at least one suicide attempt and 40 (41.8%) reported a history of self-injurious behaviors.”


There are quite a few of these studies.

 

Let me connect some dots for thought.

There is a higher rate of suicide among trans
That means an individual could be -but doesn’t have to be
What matters is the situation with this individual
This person does not have the condition

Seems like a probability of a group of people to indicate further investigation is trumping a persons real world evidence

 

Seems to be consistent with the Faa's treatment of anyone ever having any issue where alcohol was involved. They *might* be a risk, so let's make their life miserable so nobody can blame us later if they are. So much for the presumption of innocence.

 

For the FAA, that is evaluated as part of the Mental Health Status Report, which is performed by a psychiatrist. But there is nothing in the evaluation guidance that suggests continuous monitoring is appropriate. The diagnosis code is adjustment disorder, no anxiety. Why would this case be treated so harshly?

My take on this is the person who wrote the letter messed up. They either forgot to change text or just assumed it would be like HIMS because it was going to a psychiatrist. My recommendation is to ask the AME or the psychiatrist about it and see if they can clear it up. At least get an explanation why someone in OKC decided to depart from the standard.

The evaluation guidance is clear.

 

It should be treated harshly because about half of the people with this condition think about killing themselves. Do I need to explain why that might be bad?

I’m glad I was not the only one who noticed that

I’d rather the guy in the front of the plane party on the weekends, have ADD, or sleep apnea, but want to live, than be suicidal. The handling of one compared to the other makes no sense.

Again, ideally this should be the call of the doctor who has a relationship with the pilot, and has their medical license on the line, to have skin in the game.

The studies also show the suicide rate really doesn’t change with time, so the FAAs 5 year no care policy is based on???

Broken FAA system.

 

I don't understand, since my statement was that they are consistent, but you are saying "The handling of one compared to the other makes no sense."

 

True also for Veterans (Citation) Follow the footnote for LGBTQ veterans for more information

I don't like inductive reasoning. It leads to bad conclusions.

Where do you think they go next?

Evidence based medicine is sadly lacking among the "doctors" at the FAA.

This specific person should not be treated as suicidal because "Those people" are more at risk.

 

Perhaps the FAA should let real doctors make those individual calls across the board.

It is also interesting reading the reaction in other topics on this site where posters bunched people into “no place in the cockpit” for no medical diagnosis issues, like the guy who went to a bar and got stabbed, no medical diagnosis. but here, someone diagnosed with a condition that has a 50/50 suicide inclination, that’s the FAA being out of line?

Or am I misreading here??

People should be judged on a individual basis by a real doc with the license on the line.

Many here should also compare their reactions on this SI post to other SI medical topics.

 

You seem very caught up is railing against a system that isn’t what you think it should be. Neither the world nor the FAA are going to change for you.

 

Have you contacted NGPA for support?

www.NGPA.org

Paul

 

It’s our duty to being railing against issues in our government.

Do you vote?

Contact your elected representatives about issues that you see?

My dad taught me when I was a kid that we were gifted a great nation and we owe it to those who came before us to make sure it stays a great nation, I started voting right when I was old enough and have exercised and understood my rights even before that.

I don’t have kids yet, but what type of country would I leave them, or what kind of man would I be, if I just said “nothing I can do” and kicked the trash further down the street for another man to have to clean up.

 

You assume a lot.

 

So do you!

 

??? What do you think I’ve assumed that I haven’t stated as such?

 

While suicide ideation is statistically significantly higher among persons with gender dysphoria than with the general population, the reasons for this disparity are important to understand as it relates to the probability that any given individual with gender dysphoria is at risk for suicide.

The UCLA School of Law Williams Institute examines key risk factors in a 2019 study:
https://williamsinstitute.law.ucla.edu/publications/suicidality-transgender-adults/

Highlights of the study:

• Respondents who experienced discrimination or were a victim of violence were more likely to report suicide thoughts and attempts.
  
• Respondents who experienced family rejection were also more likely to report attempting suicide.
  
• Access to gender-affirming medical care is associated with a lower prevalence of suicide thoughts and attempts.

Anyone experiencing either/both of the first two circumstances - gender dysphoria or not - would be more likely to have suicidal thoughts, while individuals with gender dysphoria and access to gender-affirming medical care are less likely to have suicidal thoughts.

This isn't rocket science, folks.

 

In addition, it passes the common sense test. Societal rejection would seem to be more of a cause than than the condition itself.

 

Absolutely true. And it might even be a good idea to monitor people with conditions that promote suicide. But if we do that, we should do it broadly and take in all kinds of conditions. Job loss, divorce, severe illness, excessive caffeine use...anything that might make someone prone to suicide.

However, such continuous monitoring isn't the defined FAA evaluation criteria for gender dysphoria. So why is it being applied here?

 

When it comes to mental health and substance abuse the FAA behaves like a crazy drug addict. Irrational. But as so many on this board love to point out the FAA’s job it to protect the public and they own the air like it was granted to them by the king so you are not allowed to complain. Open up your checkbook and prepare to say whatever lies required to get the king’s approval.

 

Because some bureaucrat made an arbitrary decision to apply it and frankly you have no standing to question them… you been drinking? Not like you to question the administration’s efforts to keep the skies safe.

 

Government employees are not permitted to make arbitrary decisions. There are regulations they must work by because they are executing law and there can be no personal judgement in that action.

You don't know that?

This is very different than having a tough standard for finding alcoholics and sticking to it to the point of catching "too many". There isn't a standard that requires a gender dysphoric pilot to attend constant monitoring.