Jack Pula, MD, instructor of clinical psychiatry, was recently appointed chairperson of the Transgender Committee of the Association of Gay and Lesbian Psychiatrists.

In this role, Pula says he would like to create a network of psychiatrists and residents of all gender identities who are interested in changing the curricula of medical schools and residency programs nationwide to include training in transgender issues.

With homosexuality being removed from the DSM in 1973 and the generally positive societal shift in attitudes toward LGBT people, the tide is turning. But transgender people have not ridden the wave quite yet, according to Pula.

In the medical and psychiatric community, he explains, doctors still tend to think that transgender people are ill, "that they are by definition psychotic or personality disordered. They have not learned about transgender people who live healthy, well-adapted lives. For those who are mentally ill and transgender, they can be doubly stigmatized even by professionals who are supposed to help them," Pula says. "They often think transgender people can easily change in and out of their gender, and that it's more of a performance or cosmetic thing, as opposed to a core identity."

These assumptions have led Pula to want to change the way psychiatric residents are trained.

"The problem is that residents still don't get trained in transgender issues," Pula says. "[A transgender person] can't really go to a psychiatrist and think they're seeing an expert. They'd have to seek out an expert, and experts aren't easy to find. And the older generation of psychiatrists haven't had any training and often have a bias."

In addition to his faculty responsibilities, Pula works as an attending psychiatrist in the ER, runs an outpatient practice, is a member of the CUMC Student Mental Health Service, and is in training at the Columbia University Center for Psychoanalytic Training and Research. From his experience, Pula says that clinicians who work with transgender patients - not just transgender clinicians - are also stigmatized. There's an attitude, he says, "that there must be something wrong with them, that they have weird ideas, especially clinicians working with kids. There has been a lot of controversy about how to treat transgender kids.

"There's a tendency to not understand, to not know quite what to do with a transgender person," he says, referring not just to the medical community but society as a whole. "It is reasonable to have trouble understanding transgenderism, especially if you are not in a position to hurt someone, but doctors can hurt their transgender patients and so need to be educated on this topic. I hope to raise the level of consciousness around this issue and get people to think more deeply about it."

Pula has a unique vantage point from which to view the clinical, cultural and personal issues faced by lesbian, gay, bisexual and transgender people. He is transgender.

"As I've come out in the past year as transgender, I've had some good experiences and some not very good experiences," Pula says. "It's easy to get frustrated sometimes because you don't want to be constantly explaining yourself."

Pula joined the Columbia faculty in 2009. In the process of coming out as transgender to the CUMC community over the past year, he sent letters to doctors, residents, nurses, security staff, interpreters, and fellow trainees, with whom he works regularly. While there has been an outpouring of support and help, Pula has faced difficult challenges that are common for transgender people, including institutional medical barriers and an early reactive (but redacted) rush to judgment that threatened to delay his training.

Despite such hurdles, Pula assuredly reports that CUMC has been an open, tolerant and increasingly welcoming place, and he is enthusiastic about new efforts to create culturally competent care for transgender people. He is also heartened by the openness of resident psychiatrists on his service and sees their attitude as the wave of the future in medicine.

"People are walking on eggshells [about this situation], and they don't want to hurt anyone," he says. "And sometimes they do, and then they apologize, so it can be frustrating on both sides. But most people here at the medical center want to understand and do the right thing.

"It takes time to understand this and to adapt. Transgenderism is a phenomenon that bends basic rules our culture relies on. People need time. Our university medical center is growing and adapting towards inclusivity and greater competence, and that is truly wonderful."

Having received good support so far in his efforts as committee chairperson, Pula is optimistic that residency training programs can change.

"There's been a lot of attention paid recently by the Institute of Medicine, the Department of Health and Human Services and the media to LGBT issues," he says. "There's a movement afoot that cultural competency is important, and LGBT is part of a culture that needs to be respected."

- Mary Schiller (Columbia University)

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