The terminology of identities between, outside and beyond the gender binary - A systematic review

Inmune-mediated inflammatory rheumatic diseases in transgender people: A scoping review

BACKGROUND

In immune-mediated inflammatory rheumatic diseases (IMIRD), there are differences between cis-men and cis-women in epidemiology, clinical feature, therapeutic approach, treatment response, and prognosis. In transgender individuals, information concerning IMIRD is not substantial. The assessment of information concerning rheumatic diseases in transgenders is crucial because transgenders may undergo treatments with potential impacts on IMIRD. We aim to collect and discuss current knowledge on IMIRD in transgender individuals, determine the coverage of the literature, identify the knowledge gaps, and highlight opportunities for future research.

METHODS

We did a scoping review of publications collected through a systematic search of transgender patients with any IMIRD. Data sources were Medline, Embase, and Web of Knowledge. Synthesis of results and qualitative review of data information was collected in tables. A semi-quantification of the quality of the articles reporting clinical studies was performed.

RESULTS

There were 11 transwoman, and 3 transmen cases of systemic lupus erythematosus (5 cases), skin lupus erythematosus (2), systemic sclerosis (4), anti-synthetase syndrome (1), rheumatoid arthritis (1) and ankylosing spondylitis (1). Eleven were de novo cases and three had prior history of IMIRD and developed a comorbidity after starting hormone replacement therapy. The clinical expression of the disease was variable. Two transwomen and one transman developed thrombotic events. The lupus skin lesions in one transman improved following testosterone treatment. No clinical studies were identified. Quality of publications was disparate.

CONCLUSION

Although the number of cases is small, most cases of IMIRD occur in transwomen. The absence of solid data warrants caution in establishing recommendations regarding hormone replacement therapy in transgenders with IMIRD. There is an essential need for the consideration of cisgender and transgender particularities in future research on IMIRD.

"Having a non-normative body for me is about survival": Androgynous body ideal among trans and nonbinary individuals

The present study focused on trans and nonbinary (TNB) individuals who have an androgynous or non-stereotypical body ideal, with attention to how their body ideal is conceptualized and maintained. Data were collected online from 76 TNB individuals. Based on responses to two open-ended prompts, a two-tiered analysis was conducted. First, thematic analysis was used to develop four central themes describing the way TNB individuals conceptualized their androgynous body ideal: 1) Attaining Neutrality and De-Categorizing Gender; 2) Disaggregating Gender Expression; 3) Managing Gender Dysphoria; and 4) Achieving Authenticity. Second, content analysis was used to document 12 behaviors engaged in or actions taken for the purpose of approaching or maintaining an androgynous or non-stereotypical body ideal. These were grouped into 3 main categories: gender expression (clothes, hair, make-up, body modifications), body shape (weight, muscularity, eating/diet), and sex characteristics (hormone therapy, body hair, vocal, chest, genitals). Results of the present study expand the current body ideal literature by including TNB narratives and by focusing specifically on the ways an androgynous body ideal is conceptualized and maintained. Research and clinical implications are discussed.

Understanding the processes underlying self-harm ideation and behaviors within LGBTQ+ young people: A qualitative study

OBJECTIVE

This study aims to understand the processes underlying self-harmful thoughts and behaviors, with and without suicidal intent, among LGBTQ+ young people.

METHOD

Nineteen semi-structured interviews took place between October 2019 and May 2020. Participants were aged between 16 and 25 years, had experiences of self-harm ideation and behaviors, and were part of the LGBTQ+ umbrella. A range of sexualities and gender identities were represented: eleven participants were cisgender, six were transgender and two were non-binary. Interviews were transcribed verbatim and anonymised. Thematic analysis and reflective member-checking were used to develop a thematic framework.

RESULTS

Three themes were developed from the interviews and evaluated by four participants who engaged with reflective member-checking. Findings indicated that internal processes and external responses to being LGBTQ+ resulted in self-harmful thoughts and behaviors. Alongside these, additional stressors related to being a young person were led to difficulties with self-harm.

CONCLUSIONS

Findings from this study indicate that young people often struggle with accepting their LGBTQ+ identity for a number of reasons, whether this is due to access to a resource or their own feelings about their identity. These negative self-perceptions can be enhanced by poor responses from others and additional life stressors which impact their self-esteem or self-perception.HIGHLIGHTSUnderstanding and accepting that one is LGBTQ+ is not always a simple process, struggling with these thoughts can influence self-harm.Lack of LGBTQ+ terminology hinders self-acceptance and caused young people to engage with self-harm.Peers and family members responses to a young people's LGBTQ+ identity is highly significant and can directly led to self-harmful thoughts and experiences.

Usability of Virtual Visits for the Routine Clinical Care of Trans Youth during the COVID-19 Pandemic: Youth and Caregiver Perspectives

We evaluated families' perspectives on the usability of virtual visits for routine gender care for trans youth during the COVID-19 pandemic. An online survey, which included a validated telehealth usability questionnaire, was sent to families who had a virtual Gender Clinic visit between March and August 2020. A total of 87 participants completed the survey (28 trans youth, 59 caregivers). Overall, usability was rated highly, with mean scores between "quite a bit" and "completely" in all categories (usefulness, ease of use, interface and interaction quality, reliability, and satisfaction). Caregivers reported higher usability scores compared to trans youth [mean (SD) 3.43 (0.80) vs. 3.12 (0.93), p = 0.01]. All families felt that virtual visits provided for their healthcare needs. A total of 100% of youth and caregivers described virtual appointments as safer or as safe as in-person visits. A total of 94% of participants would like virtual visits after the pandemic; families would choose a mean of two virtual and one yearly in-person visit with a multidisciplinary team. Overall, virtual gender visits for trans youth had impressive usability. Participants perceived virtual visits to be safe. For the future, a combination of virtual and in-person multidisciplinary visits is the most desired model.

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

Gender Diversity in Peer Relations: Best Research Practices and Marshalling Peer Influence

Young people are challenging gender to expand beyond a male/female binary, yet research practices still lag behind these conceptions. This call-to-action paper will review the traditional conceptualizations of gender as prevalent in peer relations research, contrasted with modern approaches from scholars studying gender and sexual orientation diversity, and outline how youth are challenging binary conceptualizations. We provide recommended best practices to sensitively bridge this gap, including: using open responses where possible, and two-step closed-ended question formats where necessary, to measure gender identity; considering the context and role that gender identity and each of its facets might play in the research design; and preserving underrepresented groups even though they may be small. We close by exploring the ways in which the power of peer socialization can be (and likely currently are being) harnessed to support the ever-changing, diverse gender identities emergent in today's youth, and provide questions for future research.

Identifying coping strategies used by patients at a transgender health clinic through analysis of free-text autobiographical narratives

BACKGROUND

This paper presents an analysis of 32 narratives written by patients waiting for assessment at a transgender health clinic (THC) in England. Narratives are autobiographical free texts, designed to allow patients to describe in their own words their experiences of their gender identity and/or transition prior to a clinic appointment, as part of the assessment process.

OBJECTIVE

Narratives were analysed to identify actions prospective patients had taken to manage their (usually lengthy) waiting times, so that these 'coping strategies' could be shared with future patients.

DESIGN

Corpus linguistic methodology was utilized to identify common patterns across the whole corpus of text-based data, augmented with more detailed sociolinguistic analysis of individual narratives.

RESULTS

There are broad commonalities in the way the transition experience is described across the corpus in terms of presentation of key experiences and feelings. There are specific descriptions of a number of recurring coping strategies, both positive and negative.

CONCLUSION

The empowerment value of writing these narratives may be limited; the existence of recurring key features suggests that patients may feel they have to present their experiences in certain ways to be accepted for treatment. However, dissemination of some positive coping strategies may help future clients of THCs to better cope with waiting times, as well as assisting practitioners in THCs in supporting their patients during this wait.

PATIENT/PUBLIC CONTRIBUTION

The clinic's Service Users' Research Advisory Group contributed to formulating the objective and design of the study. Results were presented at the clinic's annual PPI conference.

Muscle dysmorphia: what about transgender people?

Muscle dysmorphia is characterised by a strong preoccupation with being lean and muscular, with negative psychological and social consequences. The condition mostly affects men, mainly because of sociocultural messages promoting hyper-muscular forms as ideal male figures. Relatively few studies have examined muscle dysmorphia in transgender people. Using a sample of 293 Italian adults, in this study we compared muscle dysmorphia symptoms (drive for size, appearance anxiety/avoidance and functional impairment) across 60 binary transgender (women and men whose gender identity did not conform to their biological sex), 217 cisgender (women and men whose biological sex aligns with their gender identity) and 16 non-binary people (those whose gender identity did not fall within the binary gender system). We also investigated the effect of the internalisation of body ideals on the development of muscle dysmorphia, analysing the moderating role of gender identity. Findings showed that i) transgender and cisgender men scored similarly higher on drive for size, ii) transgender men scored higher on appearance anxiety/avoidance, compared to other gender groups, iii) no differences were found in functional impairment. The effect of internalisation of body ideals on drive for size was stronger in cisgender men. Findings signal the importance of investigating risk factors for muscle dysmorphia in transgender people.

Being Trans Without Medical Transition: Exploring Characteristics of Trans Individuals from Germany Not Seeking Gender-Affirmative Medical Interventions

Until recently, trans persons were expected to align their sex characteristics as much as possible with the opposite sex. Today, research and health care, as well as the diagnostic criteria from DSM-5 and ICD-11, reflect a broader understanding of trans individuals. It encompasses diverse identities and treatment requests, including trans individuals not wanting or having decided against gender-affirmative medical interventions (GAMI). The present study explored this insufficiently studied group by (1) reviewing the existing literature regarding trans individuals not seeking GAMI and by (2) exploring their demographic and trans-related characteristics in a non-clinical online convenience sample from Germany. The literature review found one large survey with a single question on trans individuals not seeking GAMI. Beyond that, only community literature addressed the topic. The analyzed sample consisted of 415 trans participants, of whom 220 were assigned female at birth (AFAB) and 195 were assigned male at birth (AMAB). Fourteen (3.4%) reported neither previous nor planned GAMI (AFAB = 9, AMAB = 5). Trans individuals not seeking GAMI were significantly older and more often reported to identify with a non-binary gender. The two interdependent, central reasons for refusing GAMI were the avoidance of transition-related suffering and the lack of necessity for treatment. The diversification of gender, as reflected in the increasing visibility of non-binary or genderqueer gender identities, seems to go hand in hand with a diversification of transition-related treatment, including the option not to seek GAMI.

Non-Binary and Binary Gender Identity in Australian Trans and Gender Diverse Individuals

Many trans and gender diverse (TGD) people have gender identities that are not exclusively male or female but instead fall in-between or outside of the gender binary (non-binary). It remains unclear if and how those with non-binary gender identity differ from TGD individuals with binary identities. We aimed to understand the sociodemographic and mental health characteristics of people with non-binary identities compared with binary TGD identities. We performed a retrospective audit of new consultations for gender dysphoria between 2011 and 2016 in three clinical settings in Melbourne, Australia; (1) Equinox Clinic, an adult primary care clinic, (2) an adult endocrine specialist clinic, and (3) the Royal Children's Hospital, a child and adolescent specialist referral clinic. Age (grouped by decade), gender identity, sociodemographic, and mental health conditions were recorded. Of 895 TGD individuals, 128 (14.3%) had a non-binary gender. Proportions differed by clinical setting; 30.4% of people attending the adult primary care clinic, 7.4% attending the adult endocrine specialist clinic, and 8.0% attending the pediatric clinic identified as non-binary. A total of 29% of people in the 21-30-year-old age-group had a non-binary gender identity, higher than all other age-groups. Compared to TGD people with a binary gender identity, non-binary people had lower rates of gender-affirming interventions, and a higher prevalence of depression, anxiety, and illicit drug use. Tailoring clinical services to be inclusive of non-binary people and strategies to support mental health are required. Further research to better understand health needs and guide evidence-based gender-affirming interventions for non-binary people are needed.

Development of the Trans and Gender Diverse Social Anxiety Scale

Objectives: We develop and evaluate a Trans and Gender Diverse Social Anxiety Scale (TSAS) suitable for use with trans and gender diverse (TGD) people. Methods: We evaluate the TSAS on a sample of 171 TGD adults (40 transmen, 80 transwomen, and 51 gender nonbinary). We test the TSAS's construct validity against measures of perceived and enacted anti-trans stigma, and in comparison to a generic (i.e., non-TGD-specific) measure of social anxiety, the Liebowitz Social Anxiety Scale (LSAS). Results: Factor analyses reveal a four-factor structure consisting of fear and avoidance of (i) social interactions with familiar people, (ii) public scrutiny, (iii) interactions with organizations, and (iv) interactions with religious people or religious authority. Hierarchical regressions confirm that although symptoms of social anxiety assessed by the TSAS overlap with symptoms of generic social anxiety, responses to the TSAS target social situations specifically related to anti-trans stigma. MANOVAs of TSAS score by TGD gender subgroups also reveal that transmen report more social anxiety than either gender nonbinary TGD people or transwomen. Conclusions: The TSAS is a brief instrument that can be used to measure social anxiety in TGD people in social situations in which anti-trans stigma is commonly encountered.

Considering Gender-Biased Assumptions in Evolutionary Biology

Many organisms studied by evolutionary biologists have different sexes, and the evolution of separate sexes and sexual dimorphisms in morphology and behaviour are central questions in evolutionary biology. Considering scientists to be embedded in a social and cultural context, we are also subjected to the risk of gender-biased assumptions and stereotypical thinking to appear when working on topics related to sexual reproduction and sexual dimorphism. Here we present, for continued discussion, a set of good-practice guidelines aimed at (1) helping to improve researchers’ awareness of gender-biased assumptions underlying language use, generalizations, and interpretation of observations; and (2) providing recommendations to increase transparency, avoid problematic terminology, and improve study designs.