Helping Transgender People Thrive

Jae Sevelius, PhD (they/them), who joined the Department of Psychiatry at Columbia in October 2022 as a professor of medical psychology, has devoted their career to advancing health and reducing barriers to care for transgender communities. 

“Trans and gender expansive people are often socially marginalized for not conforming to rigid expectations of gender identity and expression,” Dr. Sevelius said. “Due to stigma and discrimination along with other social determinants of health, trans communities experience high rates of trauma and health disparities; this is compounded even further for trans and gender diverse people of color.”

Dr. Sevelius, who is non-binary, seeks to address such challenges and inequities through community-based research, peer-led interventions, and mentorship of early-stage investigators whose backgrounds and identities are under-represented in academic medicine. They pursues these goals through community-based research, peer-led interventions, and mentorship of early-stage investigators whose backgrounds and identities are under-represented in academic medicine.

Columbia Psychiatry News spoke with Dr. Sevelius about their personal and professional journey, what inspires their research, and their hopes for the future of mental health among transgender and gender diverse communities.

What led you to a research career committed to advancing health and wellbeing of trans and gender diverse communities?

I got my PhD in clinical psychology with the intention of becoming a therapist. During my graduate program, I took a class in psychopathology where I first encountered the diagnosis “gender identity disorder”—and was appalled. This was during a phase of my life where I was coming out as queer and genderqueer. I had been discovering feminism and feminist literature for some time, embracing an expansive sense of who I am as someone assigned female at birth but expresses myself more broadly. I couldn’t fathom why an identity or gender expression outside of a very narrow definition of gender should be medicalized and pathologized. I did my thesis on gender identity disorder and learned much more about the health disparities that transgender and gender diverse people face. After finishing my PhD, I got a postdoc position at University of California, San Francisco, and obtained an NIH K08 award to pursue a research career focused on developing behavioral interventions to address the HIV disparities faced by trans people.

I realized there were a lot of knowledge gaps and a great need for health-related research developed in collaboration with transgender communities to better reflect our priorities and concerns. As a result, I felt compelled to follow a research pathway and help promote health and quality of life among trans people, while contributing to the evidence base around the need for gender-affirming care. My clinical training deeply informs my research.

Is the concept of transgender identity as a disorder changing?

With the publication of DSM–5 (Diagnostic and Statistical Manual of Mental Disorders) in 2013, “gender identity disorder” was eliminated and replaced with “gender dysphoria.” This revision focused the diagnosis on the distress that some transgender people experience as a result of feeling that their gender identity and sex assigned at birth are not aligned, and for which they may seek psychiatric, medical, and surgical treatment. With the new emphasis, a person whose gender identity differs from their assigned sex at birth and who experiences distress can be diagnosed with gender dysphoria, which is often required for health insurance to cover their medical care. Some people feel that “dysphoria” is an improvement over “disorder” because it is the distress that is diagnosable, not the identity itself. This is an important step in depathologizing gender expansive identities. However, there remains controversy around diagnosing the distress as well. Trans and gender expansive people have always existed throughout time and across cultures—it is a natural variation of the human existence. Being trans is not a mental disorder; trans people largely suffer due to social conditions that deny and stigmatize their existence.

How did your training in clinical psychology lead you to a research career focused on HIV?

While my passion is mental health, historically most of the funding available for trans health research has been focused on HIV disparities, which are also driven by challenges in access to gender-affirming care. During my postdoc at UCSF’s Center for AIDS Prevention Studies, I learned about the extreme HIV disparities faced by transgender women, in particular, among trans women of color. Some studies have reported up to one-fifth of transgender women in the U.S.—and nearly one-half of Black/African American transgender women— are living with HIV. Once I decided to focus my research on urban trans women of color, I realized that I needed to build a team that reflects these communities to help shape the research in a way that is meaningful to them. To accomplish this, a large team of trans and gender expansive people built the UCSF Center of Excellence for Transgender Health.

I’ve led several community-based intervention studies; the one that has gone the furthest in terms of established efficacy and being adopted broadly is Healthy Divas, a peer-led intervention that provides information, support, and skills-building to trans women and empowers them to identify and accomplish health care goals related to gender affirmation and HIV prevention or treatment, depending on their status. As principal investigator on Healthy Divas, I worked with our team at UCSF to design the intervention after extensive research with community members, patients, and providers, and with federal funding we have been able to test the efficacy and examine the implementation of Healthy Divas in several sites. The program— consisting of six peer-facilitated individual sessions and one group workshop led by a peer facilitator and two health care providers—has been replicated in multiple cities across the U.S. as well as in São Paulo, Brazil. During the last few years, we’ve broadened our approach at some of the sites to include all transgender women, regardless of HIV status.

You recently received a $6 million grant from National Institute of Mental Health to improve HIV prevention and care for transgender women of color. Tell us about the project.

For this project, Dr. Kristi Gamarel, the multi-principal investigator at the University of Michigan, and I decided to take Healthy Divas, along with another intervention my team and I developed at UCSF, called Sheroes, and combine them to create a multi-level, peer-led, HIV status-neutral intervention for trans women of color, which we are calling Let’s Be. Our community-based research sites are now in New York City and Detroit. Being in New York provides access to a much larger community of transgender women, and I’m excited to partner with Dr. Asa Radix at Callen-Lorde, a community health center with locations in Manhattan, Brooklyn, and the Bronx known for its sensitive, quality health care and services designed for the LGBTQ+ community. In addition to testing its efficacy to improve health outcomes, we will be learning from the sites about the implementation of the intervention, especially whether Let’s Be can successfully incorporate telehealth options. 

Most recently, your research and clinical work has expanded to include psychedelic-assisted therapies for identity-based trauma. Do psychedelics show promise for alleviating trauma symptoms?

In 2016, I completed a certification program in psychedelic-assisted therapies and research from the California Institute for Integral Studies in San Francisco. There was promising data emerging from studies of MDMA-assisted therapy for PTSD, and I was intrigued by the idea that we might have something new and different to offer trans communities, who disproportionately suffer from PTSD. MDMA-assisted therapy is particularly interesting because it supports people in processing trauma while increasing self-compassion and compassion for others, even around traumatic experiences. Currently, MDMA is considered a Schedule 1 substance by the FDA, which makes them illegal; however, it is legal to conduct FDA-approved research in the U.S. with MDMA in collaboration with a physician who has a Schedule 1 license.

There are valiant efforts being made by researchers and policy advocates to get MDMA and other psychedelics approved by the FDA for medical use. In fact, the FDA has granted “breakthrough therapy” status to MDMA and psilocybin (the active ingredient in “magic mushrooms”) due to their demonstrated therapeutic benefits. I am interested in understanding how MDMA-assisted psychotherapy could help address identity-based trauma among trans and gender expansive people by increasing self-acceptance, or what we call internalized gender affirmation, and increase their ability to be fully self-expressed and to thrive in a society where we continue to face ongoing marginalization and pathologization. Trans and gender diverse people, however, are vastly underrepresented in clinical research, and trials of psychedelic-assisted therapy have been no different. We must ensure that transgender communities have access to these emerging therapies in an affirming way, and we must prepare therapists for practice with this population.

Are you hopeful about closing up transgender health disparities gap? Or do you feel like Sisyphus climbing up a mountain?

It's a little of both. On one hand, there are some people who are making it their job to eradicate trans people, even to make it really, really difficult for them to get access to the care that they need. And on the other hand, we know more than ever about what’s needed to support thriving trans and gender expansive communities. In some segments of society, there is growing acceptance of trans people and more support for ensuring their civil and political rights. It's important to continue to educate people, to educate our communities, our parents, our grandparents, and our children. Understanding and awareness can go a long way toward eradicating discrimination, bigotry, and hatred, and is one key to promoting health among trans and gender expansive communities.