How to manage a transgender patient on testosterone (hormone replacement therapy) therapy experiencing suicidal ideation and aggressive behavior?

Management of Transgender Patient on Testosterone with Suicidal Ideation and Aggressive Behavior

Immediately assess suicide risk through a structured interview and develop a collaborative crisis response plan while initiating cognitive behavioral therapy focused on suicide prevention, as these interventions reduce suicide attempts by 50% compared to usual care. 1

Immediate Safety Assessment and Crisis Planning

Conduct a comprehensive suicide risk assessment that includes:

• Frequency and intensity of suicidal thoughts, specific plans, access to lethal means, and history of previous attempts 1, 2
• Current psychiatric symptoms, social support availability, and recent stressors or triggers 1
• The aggressive behavior pattern: triggers, warning signs, and whether aggression is directed at self or others 1, 3

Develop a crisis response plan collaboratively with the patient that includes: 1, 2

• Identification of clear warning signs (behavioral, cognitive, affective, or physical)
• Self-management coping skills the patient can use independently
• Social support contacts (friends, family members who have helped previously)
• Crisis resources including medical providers, mental health professionals, and the suicide lifeline
• Scheduled follow-up appointments with close spacing 2

Address Testosterone Therapy Considerations

Do not automatically discontinue testosterone therapy, as gender-affirming hormone therapy generally improves mental health outcomes in transgender individuals. However, the FDA label notes that testosterone can cause mood swings and, rarely, depression with suicidal ideation. 4

• Monitor testosterone levels to ensure they are in therapeutic range (not supraphysiologic, which could contribute to irritability)
• Have a third party monitor for changes in mood, increases in agitation, or aggressive behavior 2
• Consider whether the aggressive behavior ("punching things") represents new-onset symptoms since starting testosterone or pre-existing issues

Psychotherapeutic Interventions (Primary Treatment)

Initiate cognitive behavioral therapy (CBT) focused on suicide prevention immediately, as this reduces suicide attempts by 50% and is the most strongly supported intervention. 1, 2

Consider dialectical behavior therapy (DBT) given the combination of suicidal ideation and aggressive behavior, as DBT specifically addresses emotion regulation, interpersonal effectiveness, and distress tolerance—all relevant to this presentation. 1, 2 While the 2024 VA/DoD guidelines downgraded DBT to "insufficient evidence," the clinical presentation of both suicidal and aggressive behavior makes this a reasonable option. 1

For the aggressive behavior specifically:

• Implement anger management and stress reduction techniques 1
• Teach recognition of emotional triggers and de-escalation strategies 1
• Use problem-solving therapy to improve coping with stressful life experiences 1, 2

Pharmacological Considerations

Avoid prescribing medications with high lethality in overdose (tricyclic antidepressants, large quantities of any medication) given active suicidal ideation. 2

Use benzodiazepines cautiously or avoid them, as they may increase disinhibition or impulsivity, potentially worsening aggressive behavior. 2

If comorbid depression or other psychiatric conditions are present:

• Consider SSRIs over other antidepressants due to better safety profile 2
• Ketamine infusion may be considered for rapid short-term reduction in suicidal ideation if symptoms are severe, though evidence for preventing suicide attempts is insufficient 1, 2
• Lithium may be beneficial if mood disorder is present, though 2024 guidelines note insufficient evidence for suicide prevention 1, 2

Lethal Means Safety

Restrict access to firearms, medications (including testosterone if injectable), and other lethal means. 1 This is a critical intervention regardless of other treatments.

• Collaborate with family/support persons to secure or remove firearms from the home
• Dispense medications in smaller quantities with frequent follow-up
• Address access to other means based on the patient's specific plan (if disclosed)

Follow-Up and Monitoring

Schedule definite, closely spaced follow-up appointments and contact the patient if appointments are missed. 2

Send periodic caring communications (postal mail or text messages) for 12 months, as this intervention reduces suicide deaths and attempts. 1, 2 Note that single communications are ineffective; sustained contact is necessary. 1

Consider self-guided digital interventions with CBT-based content for additional support between sessions. 2

Critical Pitfalls to Avoid

Do not rely on "no-suicide contracts"—there is no empirical evidence supporting their efficacy, and they may provide false reassurance. 2

Avoid coercive communications such as "unless you promise not to attempt suicide, I will hospitalize you," as these damage the therapeutic alliance. 2

Do not assume the patient is safe simply because they deny current suicidal intent—assess the full clinical picture including risk factors, protective factors, and behavioral indicators. 1

Do not attribute all symptoms to testosterone without proper psychiatric evaluation—embitterment, aggressive ideation, and suicidal thoughts often co-occur and require specific assessment. 3 The aggressive behavior may represent a separate issue requiring targeted intervention beyond hormone management.