Non-binary or genderqueer genders

Epidemiology of gender dysphoria and transgender identity

This review provides an update on the epidemiology of gender dysphoria and transgender identity in children, adolescents and adults. Although the prevalence of gender dysphoria, as it is operationalised in the fifth edtion of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), remains a relatively 'rare' or 'uncommon' diagnosis, there is evidence that it has increased in the past couple of decades, perhaps reflected in the large increase in referral rates to specialised gender identity clinics. In childhood, the sex ratio continues to favour birth-assigned males, but in adolescents, there has been a recent inversion in the sex ratio from one favouring birth-assigned males to one favouring birth-assigned females. In both adolescents and adults, patterns of sexual orientation vary as a function of birth-assigned sex. Recent studies suggest that the prevalence of a self-reported transgender identity in children, adolescents and adults ranges from 0.5 to 1.3%, markedly higher than prevalence rates based on clinic-referred samples of adults. The stability of a self-reported transgender identity or a gender identity that departs from the traditional male-female binary among non-clinic-based populations remains unknown and requires further study.

Mental health and quality of life in non-binary transgender adults: a case control study

Background: The social challenges that non-binary people experience, due in part to social intolerance and the lack of validation of non-binary gender identities, may affect the mental health and quality of life of this population. However, studies that have distinguished between non-binary and binary transgender identities are lacking. Aim: To compare the mental health and quality of life of a community sample of non-binary transgender adults with controls (binary transgender people and cisgender people) matched on sex assigned at birth. Method: A total of 526 participants were included. Ninety-seven were classified as non-binary and were compared with two control groups: 91 people classified as binary and 338 cisgender people. Only transgender people not on gender affirming hormone treatment or who had not undergone gender affirming surgery were included. Participants were invited to complete an online survey that included mental health and quality of life measures. Results: Non-binary people reported significantly better mental health than binary transgender people, but worse than cisgender people. Overall, there were no significant differences in quality of life between non-binary and binary transgender participants assigned male at birth and transgender females, but non-binary assigned males at birth had better scores on the psychological and social domains of quality of life than transgender males. Quality of life was better across all domains in cisgender people than transgender groups. Conclusion: There is an inequality with regard to mental health and quality of life between non-binary (and binary) transgender people and the cisgender population that needs to be addressed. The better mental health scores in non-binary people may reflect lower levels of body dissatisfaction among the non-binary population. Mental health problems and poor quality of life are likely to have social causes and hence legislative measures and broader government-led inclusive directives should be put in place to recognize and to validate non-binary identifying people.

Health disparities between binary and non binary trans people: A community-driven survey

Background: Genderqueer and nonbinary () people have remained largely invisible in health research. Previous research shows worse outcomes on health indicators for trans people when compared with cisgender controls, but the differences between binary trans and GQNB individuals are inconclusive. Aims: To compare overall health and well-being of GQNB people with controls of trans men and trans women, taking into account the impact of the additive effect of their socio-economic position, as well as their current need for gender affirming medical interventions. Methods: A community-driven survey was conducted in 2016 in five countries (Georgia, Poland, Serbia, Spain, and Sweden). Self-reported health and general well-being were analysed for differences between binary trans and GQNB respondents. The effects of multiple control variables (age, economic situation, educational level, belonging to an ethnic, religious, sexual or ability minority group, sex assigned at birth) as well as the current need for gender affirming medical interventions were controlled for. Results: The sample consisted of 853 respondents aged 16 and older, with 254 trans women (29.8%), 369 trans men (43.2%), and 230 GQNB people (26%). GQNB respondents showed significantly worse self-reported health and worse general well-being in comparison to binary trans respondents. Additional negative impacts of having a lower educational level, having more economic stress, and belonging to a disability minority group were found. Being in need of gender affirming medical interventions contributed significantly to worse self-reported health, whereas being younger contributed to worse general well-being. Discussion: In understanding health disparities between binary trans and GQNB people, it is necessary to take into account the additive effect of multiple socio-economic positions, and the current need for gender affirming medical interventions. The high proportion of GQNB respondents who report worse health outcomes highlights the need for policy makers and health-care providers in creating nonbinary-inclusive environments.

Sexuality in Adults with Differences/Disorders of Sex Development (DSD): Findings from the dsd-LIFE Study

For various reasons, sexuality of individuals with differences/disorders of sex development (DSD) may be affected. The aim of the study was to describe sexual activity, satisfaction with sex life, satisfaction with genital function, and sexual problems in people with different DSD conditions. Data were collected from 1,040 participants in Europe. Many people with a variety of DSD conditions do not appear to be satisfied with their sex life, experience a variety of sexual problems, and are less sexually active than the general population; therefore sexuality should be explicitly addressed in the care of people with DSD.

Development of a Natural Language Processing Algorithm to Identify and Evaluate Transgender Patients in Electronic Health Record Systems

Objective

To create a natural language processing (NLP) algorithm to identify transgender patients in electronic health records.

Design

We developed an NLP algorithm to identify patients (keyword + billing codes). Patients were manually reviewed, and their health care services categorized by billing code.

Setting

Vanderbilt University Medical Center.

Participants

234 adult and pediatric transgender patients.

Main Outcome Measures

Number of transgender patients correctly identified and categorization of health services utilized.

Results

We identified 234 transgender patients of whom 50% had a diagnosed mental health condition, 14% were living with HIV, and 7% had diabetes. Largely driven by hormone use, nearly half of patients attended the Endocrinology/Diabetes/Metabolism clinic. Many patients also attended the Psychiatry, HIV, and/or Obstetrics/Gynecology clinics. The false positive rate of our algorithm was 3%.

Conclusions

Our novel algorithm correctly identified transgender patients and provided important insights into health care utilization among this marginalized population.

The Co-occurrence of Gender Dysphoria and Autism Spectrum Disorder in Adults: An Analysis of Cross-Sectional and Clinical Chart Data

Quantitative studies indicate an overrepresentation of ASD in individuals with GD. This study aims to determine the prevalence of autistic traits or ASD in adults with GD using two different data collection methods: (1) cross-sectional data using the social responsiveness scale-adults (SRS-A) and the autism quotient (AQ) (n = 63). (2) Clinical chart data (n = 532). Mean SRS-A scores were significantly higher compared to a norm population. Almost 5% of the patients with GD scored above the cut-off as measured by the AQ. In 32 patients (6%), a certain ASD diagnosis was found in the patient files, which is sixfold higher compared to the general population. Significantly more "birth assigned male" were affected compared to "birth assigned female".

How Gender Identity and Treatment Progress Impact Decision-Making, Psychotherapy and Aftercare Desires of Trans Persons

The gender identity of trans individuals influences their treatment preferences, and this in turn seems to affect their individual treatment progress. However, there has been no research which—next to the impact of gender identity on treatment desires—has also investigated the influence of treatment progress using a measure which assumes various possible transition pathways of trans persons.Therefore, an online community survey of trans people was conducted in Germany in 2015. Data were collected via an online survey from a non-clinical sample of n = 415 trans individuals (over half assigned female at birth), aged 16–76 (Mean (M) = 38.12). Almost one fifth of participants embraced non-binary or genderqueer (NBGQ) identities. Participants progressed 60.77% (standard deviation (SD) = 35.21) through treatment at point of data collection, as measured by the individual treatment progress score (ITPS). All participants, especially participants assigned male at birth, differed significantly in desire to participate in decision-making processes based on transition progress; individuals without treatment experience had less desire to decide treatment plans. NBGQ participants assigned male at birth in early stages of transition had significantly more desire for psychotherapy during transition than participants of the same identity in later transition stages. All participants, especially binary participants, significantly differed in desire for aftercare based on transition progress; individuals without treatment experience indicated more desire for aftercare. Results indicate health professionals should expect changing treatment desires in trans individuals at various stages of transition, particularly at treatment start, and based on gender identity.

Queer Intimacies: A New Paradigm for the Study of Relationship Diversity

Recognition of sexual and gender diversity in the 21st century challenges normative assumptions of intimacy that privilege heterosexual monogamy and the biological family unit, presume binary cisgender identities, essentialize binary sexual identities, and view sexual or romantic desire as necessary. We propose a queer paradigm to study relationship diversity grounded in seven axioms: intimacy may occur (1) within relationships featuring any combination of cisgender, transgender, or nonbinary identities; (2) with people of multiple gender identities across the life course; (3) in multiple relationships simultaneously with consent; (4) within relationships characterized by consensual asymmetry, power exchange, or role-play; (5) in the absence or limited experience of sexual or romantic desire; (6) in the context of a chosen rather than biological family; and (7) in other possible forms yet unknown. We review research on queer relational forms, including same-sex relationships; relationships in which one or more partners identify as transgender, gender nonbinary, bisexual, pansexual, sexually fluid, "mostly" straight, asexual, or aromantic; polyamory and other forms of consensual nonmonogamy; kink/fetish relationships; and chosen families. We argue that a queer paradigm shifts the dominant scientific conception of relationships away from the confines of normativity toward an embrace of diversity, fluidity, and possibility.

Four Decades of Epidemiologic Science on HIV Infection and Disease, and Its Impact on Public Health Practice and Policy for Sexual and Gender Minority Persons

Even at the cusp of the second decade of the new millennia, HIV continues to be a significant public health challenge for sexual and gender minorities (SGM). Men who have sex with men and transgender women, in particular, continue to report higher rates of HIV incidence compared to their heterosexual counterparts, while facing significant barriers to comprehensive sexual healthcare. In Delaware, HIV infection impacts a substantial number of individuals with approximately 14.5 incident cases per 100,000. This ranks Delaware as the 14th highest for HIV incidence among U.S. states. However, the largest healthcare provider in Delaware, Christiana Care Health System, has created many health initiatives to support the health needs of SGM and those living with HIV. The current sustained rate of HIV infection indicates the need for enhanced epidemiologic work to identify HIV cases in subgroups of diverse sexuality and gender identity, collaboration within and across research institution and community organizations, as well as engagement in creative solutions that target the multiple levels of factors contributing to HIV incidence. In addition, it is imperative that local agencies and health organizations continue to support these communities of SGM individuals during the current sociopolitical climate of the national U.S. government.

Thinking an ethics of gender exploration: Against delaying transition for transgender and gender creative youth

Youth explore their genders - both theirs and those of others. Exploration is not only a vessel of discovery and understanding but also of creation. Centring the notion of gender exploration, this article inquires into the ethical issues surrounding care for transgender youth. Arguing that exploration is best seen not as a precondition to transition-related care but as a process that can operate through transitioning, the article concludes that the gender-affirmative approach to trans youth care best fosters youth's capacity for healthy exploration. Unbounded social transition and ready access to puberty blockers ought to be treated as the default option, and support should be offered to parents who may have difficulty accepting their youth.

Review of the literature on self-injurious thoughts and behaviours in gender-diverse children and young people in the United Kingdom

International literature suggests that gender-diverse people are at increased risk of thoughts and acts of self-injury compared to their cisgender peers. The current review aimed to investigate the prevalence of self-injurious thoughts and behaviours (SITBs) among children and young people (CYP) in the United Kingdom identifying as a gender not typically associated with the sex they were assigned at birth and, further, to examine relevant prevalence rates of SITBs reported both in academic and grey literature. In total, seven studies were included in the review and indicated an increased prevalence of SITBs among gender-diverse CYP compared to the general population. However, methodological limitations and significant heterogeneity in the rates of SITBs reported require that the available literature be interpreted with some caution. Important factors to consider when interpreting SITB rates, as well as recommendations for future research, are discussed.

Gender diversity and non-binary presentations in young people attending the United Kingdom's National Gender Identity Development Service

There has been a recent rise in the number of people who hold a non-binary gender identity. However, the proportion of young people attending gender services who identify as non-binary has not yet been investigated. This article presents the findings from a pilot study of newly designed questionnaire, the Gender Diversity Questionnaire, which included questions about gender identity and gender expression. Responses from 251 adolescents attending the United Kingdom's National Gender Identity Development Service between June 2016 and February 2017 are reported here. The majority, 56.9%, of young people identified as trans, 29.3% identified as a binary gender (male or female), 11% identified as non-binary and 1.2% as agender. There were no significant differences in self-defined identities based on assigned gender or age. However, once young people were separated into these groups, some of them were very small; thus, a larger sample is required. In terms of aspects of gender expression that were important to the young people, the data formed five themes - name and pronouns, external appearance, the body, intrinsic factors and 'other'. Strengths and weaknesses of the research are discussed as well as future work that will be conducted.

The Salt without the Girl: Negotiating Embodied Identity as an Agender Person with Cystic Fibrosis

In this manuscript, I build and expand on prior work by myself (Nowakowski, 2016) and others exploring the dynamics of embodiment among people with chronic health conditions. Specifically, I critically investigate the intersecting social and medical elements of responses to bodies perceived as too thin and otherwise lacking in physical ability, using my own experiences of living and aging with cystic fibrosis (CF) as a case example. In these explorations, I center gendered identity and its intersection with disabling physical illness. I do so by using my own lived experiences as autoethnographic anchor points to guide critical review of key concepts from the nexus of these two content areas. I focus throughout on exploring how others’ reactions to a frail-looking body often constitute a form of forced gendering via the narratives people attempt to construct for why a person’s body appears that way. The title of the manuscript supports this framework by referencing three cornerstones of patient experience in the CF community: the general trend of patients having salty skin due to the pathology of the disease, a prior embodiment project called Salty Girls (Pettigrew, 2012) that engages this idea, and the more abstract concept of “saltiness” in describing the grit marginalized people display in responding to microaggressions.

Gender congruence and body satisfaction in nonbinary transgender people: A case control study

Background: Binary transgender people access gender affirming medical interventions to alleviate gender incongruence and increase body satisfaction. Despite the increase in nonbinary transgender people, this population are less likely to access transgender health services compared to binary transgender people. No research has yet understood why by exploring levels of gender congruence and body satisfaction in nonbinary transgender people. Objective: The aim of this study was to compare levels of gender congruence and body satisfaction in nonbinary transgender people to controls [binary transgender people and cisgender (nontrans) people]. Method: In total, 526 people from a community sample in the UK took part in the study (97 nonbinary, 91 binary, and 338 cisgender identifying people). Participants were asked to complete an online survey about gender congruence and body satisfaction. Results: There were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender and body satisfaction compared to binary transgender people. However, there was no difference in congruence and satisfaction with social gender role between the two transgender groups (nonbinary and binary). Cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary). Conclusions: There are differences in gender congruence and body satisfaction between nonbinary and binary transgender people. Nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people. Transgender health services need to be more inclusive of nonbinary transgender people and their support and treatment needs, which may differ from those who identify within the binary gender system.

Endocrinology of Transgender Medicine

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.

Healthcare Experiences Among Young Adults Who Identify as Genderqueer or Nonbinary

PURPOSE

Research on healthcare among gender-diverse populations has largely focused on people who describe their gender in binary terms, either as trans men or trans women. This qualitative study examined the healthcare experiences of young adults who identify as genderqueer or nonbinary (GQ/NB).

METHODS

Participants (N = 10) were interviewed about experiences seeking and accessing healthcare. All were young adults (ages 23-33) in the San Francisco Bay area who had accessed healthcare at least once in the prior 6 months. A semistructured interview guide elicited conversations about gender identity and experiences of healthcare. Interview transcripts were analyzed using emergent coding analysis to identify themes.

RESULTS

Participants faced unique challenges even at clinics specializing in gender-affirming healthcare. They felt misunderstood by providers who approached them from a binary transgender perspective and consequently often did not receive care sensitive to nonbinary identities. In response to this perceived bias, participants sometimes "borrowed" a binary transgender label to receive care, modified the healthcare they were prescribed, or went without healthcare. The GQ/NB young adults in our study regularly felt disrespected and frustrated as they sought and accessed healthcare. Participants felt that the binary transgender narrative pressured them to conform to binary medical narratives throughout healthcare interactions.

CONCLUSIONS

GQ/NB young adults have unique healthcare needs but often do not feel understood by their providers. There is a need for existing healthcare systems to serve GQ/NB young adults more effectively.

Self-Reported Gender Identity and Sexuality in an Online Sample of Cisgender, Transgender, and Gender-Diverse Individuals: An Exploratory Study

The relations between self-reported aspects of gender identity and sexuality were studied in an online sample of cisgender (n = 4,954), transgender (n = 406), and gender-diverse (n = 744) groups. Aspects of gender identity and sexual fantasies, attraction, behavior, and romantic relations were assessed using the Multi-gender Identity Questionnaire (Multi-GIQ) and a sexuality questionnaire. Results show a wide spectrum of gender experiences and sexual attractions within each group, an overlap among the groups, and very weak relations between atypical gender identity and atypical sexuality. At the group level, aspects of gender identity and sexuality were mainly predicted by gender and sex-gender configuration, with little contribution of sex assigned at birth. A principal component analysis (PCA) revealed that measures of gender identity and of sexuality were independent, the structure of sexuality was mostly related to gender, whereas the structure of gender identity was mostly related to sex-gender configuration. The results of both approaches suggest that measures of gender identity could roughly be divided into three classes: one including feeling as a man and feeling as a woman; a second including measures of nonbinary and "trans" feelings; and a third including feeling as a "real" woman and feeling as a "real" man. Our study adds to current scientific data that challenge dichotomous conventions within gender identity and sexuality research. Possible social and clinical implications are discussed.

Predictive validity of the genderqueer identity scale (GQI): differences between genderqueer, transgender and cisgender sexual minority individuals

Introduction: The Genderqueer Identity Scale (GQI; McGuire et al., this issue) - a newly developed and validated measure - assesses genderqueer identity via four subscales: challenging the gender binary, the extent to which participants actively work to dismantle gender binaries in identity and expression); social construction of gender, or the degree to which participants interpret their gender identity as something that develops versus an innate essentialist phenomenon; theoretical awareness of gender, the degree of social and political intention attached to gender identity; and gender fluidity, or repeated shifting of gender expression across periods of time. Aim: This descriptive study examined the predictive validity of the GQI and group differences in genderqueer identity with a sample of transgender, genderqueer and nonbinary spectrum, and cisgender sexual minority adults (N = 510). Methods: We hypothesized that Genderqueer Non-binary (GQNB) participants would score higher on GQI subscale scores compared to transgender participants who identify within the gender binary. Results: Results from ANOVA models indicated a statistically significant difference in intrapersonal subscales across sexual minority and transgender binary or genderqueer groups. For the interpersonal subscales there were differences across all three groups. Cisgender sexual minority participants reported the lowest levels on all scales, while genderqueer participants reported the highest, and transgender binary were in-between. Discussion: The GQI demonstrates strong predictive validity in distinguishing binary transpersons from GQNB and cisgender sexual minority persons. Findings reveal that these three subgroups who might otherwise be similarly categorized (i.e., LGBTQ) show significant differences on challenging the binary, social construction, theoretical awareness, and gender fluidity constructs.

The gender affirmative lifespan approach (GALA): A framework for competent clinical care with nonbinary clients

Background: The limited research on nonbinary individuals suggests that this community experiences significant health disparities. Compared to binary transgender individuals, research suggests that nonbinary individuals are at elevated risk for discrimination and negative mental health outcomes, including depression, anxiety, traumatic stress, and suicidality. Even mental health providers who work with binary transgender individuals often lack knowledge of and training to work competently with nonbinary individuals. Methods: The authors of this conceptual article present the Gender Affirmative Lifespan Approach (GALA), a psychotherapy framework based in health disparities theory and research, which asserts that therapeutic interventions combating internalized oppression have the potential to improve mental health symptomatology resulting in improved overall health and well-being for gender diverse clients. GALA's therapeutic interventions are designed to promote positive gender identity development through five core components: (1) building resiliency; (2) developing gender literacy; (3) moving beyond the binary; 4) promoting positive sexuality; and (5) facilitating empowering connections to medical interventions (if desired). Results: The core components of the GALA model are individualized to each client's unique needs, while taking into consideration age and acknowledging developmental shifts in, or fluidity of, gender across the lifespan. This model represents an inclusive, trans-affirmative approach to competent clinical care with nonbinary individuals. Discussion: Application of the GALA model with nonbinary clients is discussed, including one clinical case vignette.

Associations between gender equality and health: a systematic review

This systematic review sought to evaluate the impact of gender equality on the health of both women and men in high-income countries. A range of health outcomes arose across the 48 studies included. Gender equality was measured in various ways, including employment characteristics, political representation, access to services, and with standard indicators (such as the Global Gender Gap Index and the Gender Empowerment Measure). The effects of gender equality varied depending on the health outcome examined, and the context in which gender equality was examined (i.e. employment or domestic domain). Overall, evidence suggests that greater gender equality has a mostly positive effect on the health of males and females. We found utility in the convergence model, which postulates that gender equality will be associated with a convergence in the health outcomes of men and women, but unless there is encouragement and support for men to assume more non-traditional roles, further health gains will be stymied.

Prevalence of the Wish to be of the Opposite Gender in Adolescents and Adults with Autism Spectrum Disorder

Several studies have suggested an overrepresentation of (symptoms of) autism spectrum disorder (ASD) among individuals with gender dysphoria. Three studies have taken the inverse approach in children with ASD and showed increased parent report of the wish to be of the opposite gender in this group. This study compared the self-reported wish to be of the opposite gender (one item of the Youth Self-Report [YSR] and the Adult Self-Report [ASR]) of 573 adolescents (469 assigned boys and 104 assigned girls) and 807 adults (616 assigned males and 191 assigned females) with ASD to 1016 adolescents and 846 adults from the general population. Emotional and behavioral problems were measured by the DSM-oriented scales of the YSR and ASR. In addition, the Children's Social Behavior Questionnaire and the Adult Social Behavior Questionnaire were used to measure specific subdomains of the ASD spectrum to test whether specific subdomains of ASD were particularly involved. Significantly more adolescents (6.5%) and adults (11.4%) with ASD endorsed this item as compared to the general population (3-5%). In adolescents, assigned girls endorsed this item more than assigned boys. No significant gender differences were found in the adults with ASD. In addition, on all DSM-oriented scales of both the YSR and ASR, adolescents and adults with ASD who endorsed the gender item had significantly higher scores compared to those without. There were no significant associations between endorsement of the gender item and any specific subdomain of ASD, providing no evidence for a sole role of one of the ASD subdomains and endorsement of the wish to be the opposite gender.

Nonconforming Gender Expression and Associated Mental Distress and Substance Use Among High School Students

IMPORTANCE

The cultural roles and expectations attributed to individuals based on their sex often shape health behaviors and outcomes. Gender nonconformity (GNC) (ie, gender expression that differs from societal expectations for feminine or masculine appearance and behavior) is an underresearched area of adolescent health that is often linked to negative health outcomes.

OBJECTIVE

To examine the associations of GNC with mental distress and substance use among high school students.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study based on data from the Youth Risk Behavior Survey (YRBS) conducted in 2015. The setting was 3 large urban US school districts (2 in California and 1 in Florida). Participants were a racially/ethnically diverse population-based sample of 6082 high school students representative of all public school students in grades 9 through 12 attending these 3 school districts.

MAIN OUTCOMES AND MEASURES

Sex-stratified adjusted prevalence ratios (APRs) (adjusted for race/ethnicity, grade, and sexual identity) for high gender-nonconforming students (very/mostly/somewhat feminine male students or very/mostly/somewhat masculine female students) and moderate gender-nonconforming students (equally feminine and masculine students) relative to a referent group of low gender-nonconforming students (very/mostly/somewhat masculine male students or very/mostly/somewhat feminine female students).

RESULTS

Among 6082 high school students, 881 (15.9%) were white, 891 (19.1%) black, 3163 (55.1%) Hispanic, and 1008 (9.9%) other race/ethnicity. Among female students (2919 [50.0% of the study population]), moderate GNC was significantly associated with feeling sad and hopeless (APR, 1.22; 95% CI, 1.05-1.41), seriously considering attempting suicide (APR, 1.41; 95% CI, 1.14-1.74), and making a suicide plan (APR, 1.52; 95% CI, 1.22-1.89); however, substance use was not associated with GNC. Among male students (3139 [50.0% of the study population]), moderate GNC was associated with feeling sad and hopeless (APR, 1.55; 95% CI, 1.25-1.92); high GNC was associated with seriously considering attempting suicide (APR, 1.72; 95% CI, 1.16-2.56), making a suicide plan (APR, 1.79; 95% CI, 1.17-2.73), and attempting suicide (APR, 2.78; 95% CI, 1.75-4.40), as well as nonmedical use of prescription drugs (APR, 1.81; 95% CI, 1.23-2.67), cocaine use (APR, 2.84; 95% CI, 1.80-4.47), methamphetamine use (APR, 4.52; 95% CI, 2.68-7.61), heroin use (APR, 4.59; 95% CI, 2.48-8.47), and injection drug use (APR, 8.05; 95% CI, 4.41-14.70).

CONCLUSIONS AND RELEVANCE

This study suggests mental distress is associated with GNC among female and male students. Substance use also appeared to be strongly associated with GNC among male students. These findings underscore and suggest the importance of implementing school-based programs to prevent substance use and promote student mental health that are inclusive of gender diversity in students.

A Cross-Sectional Multicenter Study of Multidimensional Body Image in Adolescents and Adults with Gender Dysphoria Before and After Transition-Related Medical Interventions

Persistent feelings of gender dysphoria (GD) are accompanied by distress and body dissatisfaction in most clinically referred adolescents and adults. Transition-related medical interventions (e.g., puberty suppression, hormones, or surgery) may alleviate body dissatisfaction. The aim of the present cross-sectional study was to compare multidimensional body image across clinically referred adolescents and adults undergoing different transition-related medical interventions. Two clinical samples of adolescents (n = 82) and adults (n = 120) referred to specialized departments of four different transgender health services in Germany participated in the study. In total, 202 individuals from the female-to-male (FtM individuals) and male-to-female (MtF individuals) spectrum aged 14-74 years were included at different stages of their transition. Four scales assessing multidimensional aspects of body image (measured by the Body Image Assessment Questionnaire, FBeK) were compared across three groups: sample, gender, and medical interventions (while controlling for age and treatment duration). The results indicated less favorable body image scores compared with the norm in both adolescents and adults with GD. Individuals who had undergone transition-related medical interventions presented a significantly better body image on two of the four scales. Differences according to gender and age were also present. These findings suggest that medical interventions, especially gender-affirming hormones and surgery, are generally beneficial to the body image in individuals with GD. However, not all of the less favorable outcomes in multidimensional body image were positively influenced by the treatment conditions and may thus benefit from additional integrative counseling before and during transition.

Man, Woman, "Other": Factors Associated with Nonbinary Gender Identification

Using a unique dataset of 7479 respondents to the online Australian Sex Survey (July-September 2016), we explored factors relevant for individuals who self-identify as one of the many possible nonbinary gender options (i.e., not man or woman). Our results identified significant sex differences in such factors; in particular, a positive association between female height, higher educational levels, and greater same-sex attraction (female-female) versus a negative effect of lower income levels and more offspring. With respect to sex similarities, older males and females, heterosexuals, those with lower educational levels, and those living outside capital cities were all more likely to identify as the historically dichotomous gender options. These factors associated with nonbinary gender identification were also more multifaceted for females than for males, although our interaction terms demonstrated that younger females (relative to younger males) and nonheterosexuals (relative to heterosexuals) were more likely to identify as nonbinary. These effects were reversed, however, in the older cohort. Because gender can have such significant lifetime impacts for both the individual and society as a whole, our findings strongly suggest the need for further research into factors that impact gender diversity.

"I love you as both and I love you as neither": Romantic partners' affirmations of nonbinary trans individuals

Background: Transgender microaffirmations are subtle endorsements of a person's gender identity through both verbal acknowledgements and behavioral gestures. Microaffirmations positively impact individuals who identify as transgender by acknowledging their gender identity and by communicating a sense of support and validation. Aims: This study focuses on microaffirmations specifically directed toward nonbinary transgender individuals within romantic relationships. Methods: Participants included 161 adults who identified as nonbinary: 85 who identified as gender nonconforming and 76 who identified as agender. These participants were either currently in a romantic relationship or had been in a romantic relationship within the past 5 years. Participants completed an online survey and provided examples of the microaffirmations they experienced from their romantic partners. Results: Responses were analyzed via thematic analysis, resulting in four overarching themes: (1) Identity Validations, acknowledgement and acceptance of nonbinary identity; (2) Identity Endorsements, active endorsements of nonbinary through language or behavior; (3) Active Learning, self-education about nonbinary identities; and (4) Active Defense, interruptions of others' negative actions directed at nonbinary partners. Discussion: Discussion of the results focuses on understanding how microaffirmations operate to complicate binary notions of gender/sex and positively influence nonbinary transgender individuals in interpersonal relationships.

Sexual and Gender Diversities: Implications for LGBTQ Studies

This think piece provides a critical analysis of the terms lesbian, gay, bisexual, transgender, and queer (LGBTQ) from an international perspective that draws on citizenship studies, providing some indications of the implications for LGBTQ studies. It outlines difficulties with the LGBTQ acronym in the Global North and South. Internationally, scholarship to support the human rights of non-heterosexuals and gender-diverse people is badly needed, but the think piece concludes that it is crucial to consider the social context of different cases, and to address the materialist, cultural, neo-colonial, and other forces that affect the formation of non-heterosexual and gender-diverse identities.

Queer ethics and fostering positive mindsets toward non-binary gender, genderqueer, and gender ambiguity

Background: Alongside the growth in visibility of gender identities and presentations such as genderqueer, non-binary and gender neutral, there is ridicule and backlash in wider culture, as well as more subtle invisibility and misgendering. While there exists social psychology research about negative and positive attitudes to trans people, this is restricted to those whose gender identity is at odds with their sex assigned at birth, and who identify with binary gender. Social psychology has extended to the more subtle workings of transphobia, but there is little consideration of the distinctiveness of attitudes and responses to those whose genders cannot be attributed in binary ways, and thus how these may be challenged. Methods: In keeping with the methods of social theory, this article brings together a diverse and complementary range of conceptual fields in new ways to diagnose a novel cause and solution to these negative attitudes. Using queer theory, feminist ethics, and empirical studies in post-tolerance sociology and social psychology, it argues that negative social responses to genderqueerness stem not only from overt prejudice in the form of transphobia but from binary genderism, the conviction that there are only two genders. Results and conclusion: This article proposes fostering greater diversity-literacy and empathy for difference as a more effective approach than minority identity-based 'prejudice reduction' approaches. A norm-critical approach to deconstructing gender norms is proposed, thus fostering positive attitudes to genderqueerness. It is therefore demonstrated how best to foster enabling social contexts for genderqueerness, with positive implications for the physical and social health and wellbeing of gender variant people. This approach can be applied in organizations, institutions, and by service providers who interact with genderqueer individuals, in that it can inform a shift to approaching diversity positively in ways that are not restricted to pre-determined and binary identity categories.

Individuals seeking gender reassignment: marked increase in demand for services

Aims and methodTo describe the pattern of referrals and characteristics of people aged over 18 seeking gender reassignment in Oxfordshire over a 6-year period (2011-2016).

RESULTS

A total of 153 individuals attended for assessment (of 162 referred); 97 (63.4%) were natal males and 56 (36.6%) were natal females. Mean age at referral was markedly different between the two groups, with females being younger. The number of referral significantly increased over the time period, by an average of 18% per year (95% CI 1.08-1.30). Eighty-seven patients sought transition from male to female, and 46 from female to male, while a smaller group (n = 13) had non-binary presentations. Twelve patients (7.8%) had autism spectrum disorder.Clinical implicationsThere are various possible reasons for the increased demand for services for people with gender dysphoria, which we discuss here. When planning services in the UK, both the increase in overall referral rates and the apparent earlier age at referral should be taken into account.Declaration of interestNone.

Effects of romantic involvement on substance use among young sexual and gender minorities

BACKGROUND

Sexual and gender minority (SGM) adolescents and young adults experience elevated rates of alcohol and drug use; it is, therefore, important to identify protective factors that decrease risk for substance use in this population. This study examined whether involvement in a romantic relationship, a well-established protective factor against heavy drinking and drug use among heterosexual adults, is also protective for SGM youth.

METHODS

This study used eight waves of data provided by a community sample of 248 racially diverse SGM youth (ages 16-20 years at baseline). Multilevel structural equation models were used to assess within-person associations between relationship involvement and use of alcohol, cigarettes, marijuana, and other illicit drugs. Age, gender, and sexual identity were tested as moderators.

RESULTS

Romantic involvement was associated with less drinking for all participants (Rate Ratio = 0.64) and decreased likelihood of illicit drug use for gay and lesbian participants (Odds Ratio = 0.56). However, participants reported smoking 26% more cigarettes when romantically involved. Further, among bisexuals, romantic involvement was associated with increased marijuana (Rate Ratio = 2.31) and other illicit drug use (Odds Ratio = 2.39).

CONCLUSIONS

Study findings indicate some protective effects of relationship involvement against substance use among SGM youth, particularly with respect to alcohol and illicit drugs other than marijuana. However, dating may promote smoking in all SGM youth and drug use in bisexual youth. The demographic differences observed in the effects of romantic involvement highlight the importance of attending to differences among SGM youth in research, theory, and substance use reduction efforts.

Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents

As a traditionally underserved population that faces numerous health disparities, youth who identify as transgender and gender diverse (TGD) and their families are increasingly presenting to pediatric providers for education, care, and referrals. The need for more formal training, standardized treatment, and research on safety and medical outcomes often leaves providers feeling ill equipped to support and care for patients that identify as TGD and families. In this policy statement, we review relevant concepts and challenges and provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as TGD while eliminating discrimination and stigma.

Barriers to insurance coverage for transgender patients

Transgender people report discrimination in access to health care that is associated with numerous poor health outcomes, including higher prevalence of HIV infection, substance use disorders, and suicide attempts. The field of obstetrics and gynecology is uniquely positioned to meet a wide range of health care needs for transgender people, and obstetrician-gynecologists can and ought to provide gender-affirming care for these patients. Despite growing evidence that gender-affirming care is both necessary and cost-effective, transgender patients continue to face barriers to securing insurance coverage, which prevents clinicians from practicing standards of care. The purpose of this article is to delineate the major barriers transgender patients face when seeking insurance reimbursement for services routinely available to cisgender (nontransgender) women.

Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services

BACKGROUND

Depression is a serious disorder which significantly impacts wellbeing and quality of life. Studies exploring mental wellbeing in the transgender population are mostly limited by small, non-homogenous samples and lack of matched controls. This study aimed to address these limitations and explore depression rates in a large sample of transgender people, compared with matched controls from the general population, as well as factors predicting depression in those taking cross-sex hormone treatment (CHT) compared to those not.

METHODS

Transgender individuals (n = 913) completed a measure of depression, measures which predict psychopathology (self-esteem, victimization, social support, interpersonal problems), and information regarding CHT use. Participants were matched by age and experienced gender with adults from the general population who had completed the measure of depression.

RESULTS

Individuals were categorized as having no, possible or probable depressive disorder. Transgender individuals not on CHT had a nearly four-fold increased risk of probable depressive disorder, compared to controls. Older age, lower self-esteem, poorer interpersonal function and less social support predicted depressive disorder. Use of CHT was associated with less depression.

LIMITATIONS

Participants were attending a national gender identity service and therefore represent only a sub-group of transgender people. Due to the cross-sectional design, longitudinal research is required to fully confirm the finding that CHT use reduces depression.

CONCLUSION

This study confirms that non-treated transgender individuals have an increased risk of a depressive disorder. Interventions offered alongside gender affirming treatment to develop interpersonal skills, increase self-esteem and improve social support may reduce depression and prepare individuals for a more successful transition.

Is Man the Measure of All Things? A Social Cognitive Account of Androcentrism

Androcentrism refers to the propensity to center society around men and men's needs, priorities, and values and to relegate women to the periphery. Androcentrism also positions men as the gender-neutral standard while marking women as gender-specific. Examples of androcentrism include the use of male terms (e.g., he), images, and research participants to represent everyone. Androcentrism has been shown to have serious consequences. For example, women's health has been adversely affected by over-generalized medical research based solely on male participants. Nonetheless, relatively little is known about androcentrism's proximate psychological causes. In the present review, we propose a social cognitive perspective arguing that both social power and categorization processes are integral to understanding androcentrism. We present and evaluate three possible pathways to androcentrism deriving from (a) men being more frequently instantiated than women, (b) masculinity being more "ideal" than femininity, and/or (c) masculinity being more common than femininity.

Effects of participation in and connectedness to the LGBT community on substance use involvement of sexual minority young people

INTRODUCTION

Research shows disproportionate levels of substance use among sexual minority young people. A range of reasons for these disparities have been suggested, including connectedness to and participation in the LGBT community. Little is known about how these constructs are related to substance use involvement in sexual minority (sub)groups or how these relationships are affected by other factors.

METHODS

1266 young sexual minority Australians completed a cross-sectional online survey. Multiple regressions were conducted to assess associations between connectedness to and participation in the LGBT community on substance use involvement, before and after controlling for other factors such as substance use motives, psychological distress, wellbeing, resilience, minority stress, and age.

RESULTS/CONCLUSION

Most participants identified as homosexual (57%, n=726) and male (54%, n=683). In the overall sample, participation in and connectedness the LGBT community were significantly associated with increased substance use involvement before (F(2,1263)=35.930, p≤0.001, R²=0.052) and after controlling for other variables (F(8,1095)=33.538, p≤0.001, R²=0.191), with meaningfully higher effect sizes for participation than for connectedness. After controlling for other variables, connectedness only remained significant for homosexuals. Effect sizes for participation were higher for females than males, and bisexuals than homosexuals. However, participation in the LGBT Community was not associated with substance use in participants identifying with a non-binary gender identity. In conclusion, substance use involvement was associated with participation in the LGBT community, but connectedness to the LGBT community only had a weak association with substance use involvement in the homosexual subgroup.