The Demographics of the Transgender Population

Gender Minority Stressors and Psychological Distress Among Chinese Transgender and Gender Diverse People: Variable-Centered, Person-Centered, and Psychological Network Approaches

Mental health disparities in transgender and gender diverse (TGD) populations call for more research examining gender minority stressors (GMS) as antecedents to their psychological distress, especially for the long-underrepresented groups living in conservative societies towards gender minorities. Furthermore, some questions remain underexamined, including the relative, independent influences of various GMS on TGD people's mental well-being (i.e., uniqueness of each stressor); how these stressors would configurate with each other in distinctive patterns to characterize subgroups of TGD people (i.e., beyond-average heterogeneity); and how these stressors would constitute a psychological network and vary in their centrality in that network (i.e., holistic complexity). To narrow such gaps, we examined the links between GMS and TGD people's psychological distress, using survey data collected in 2023 from 410 Chinese TGD people (Meanage = 22.33 years, SD = 4.27; 306 transgender, 70 non-binary/gender-queer/gender-fluid, 26 agender/gender-neutral, 3 intersex, and 5 others). We approached such links from three perspectives. First, variable-centered analyses indicated that while different GMS were considered simultaneously, internalized transphobia, preoccupation with gender dysphoria, and gender-related victimization were uniquely associated with psychological distress. Second, person-centered analyses yielded a 3-profile solution. Psychological distress varied systematically across profiles. Last, network analyses revealed a 3-cluster structure: Distal, Proximal Internal, and TGD-Specific Stressors. Preoccupation with gender dysphoria was the most central node. These findings contribute to a more nuanced understanding of the implications of GMS for TGD people's mental well-being. GMS related to internal struggles with gender identity might be among the central intervention targets to prevent/reduce TGD people's psychological distress.

Gender Characteristics and Population Size Estimation of Transgender People: A Field-Based Study from Iran

Purpose

We determined the size of the transgender population in Shiraz, Iran.

Methods

In this cross-sectional study, the respondent-driven sampling technique was used by choosing eight seeds, three waves, and six coupons for each participant. The estimated population size was calculated by wisdom of the crowds, multiplier, and successive sampling-population size estimation (SS-PSE) methods. Pooling of results was done by an Anchored Multiplier calculator.

Results

The mean age of participants (n=200) was 22.7±4 years, 197 (98.5%) were single, 86 (43%) were educated <12 years, 25 (12.5%) were not living with their families, and 52 (26%) were not financially supported by their parents. The transgender population was estimated by the wisdom of the crowds, multiplier, and SS-PSE methods to be 300 (95% confidence interval [CI]: 200-400), 677 (95% CI: 655-696), and 665 (95% CI: 624- 677), respectively. Their prevalence was found to be 0.017% (95% CI: 0.011-0.022%), 0.038% (95% CI: 0.036-0.039%), and 0.037% (95% CI: 0.034-0.038) using the same methods, respectively. Pooled results revealed that 22-37 per 100,000 general population were transgender individuals. Weighted estimation showed that trans men (56.6%) are more prevalent than trans women (43.4%), and only 17% of transgender people succeeded in gender reassignment.

Conclusion

Transgender people should not be considered as marginalized groups of the community; they should be respected, heard, and valued. Establishing a standard and routine procedure for the collection of data on the status of transgender people and gender identity is necessary for policymaking and intervention programs.

Transformative tales: The role of story videos on children's reasoning about transgender identities

The current study explored whether positive contact through stories could influence how young children think about transgender identities and gender in general. A total of 174 children ages 5-6 and 9-10 were randomly assigned to one of three conditions: Jazz (participants watched a video regarding a transgender child named Jazz), Blue (participants watched a video regarding a marker that looked red on the outside but inside was really blue) and control (no video). Both videos described the main character as feeling different inside than outside, and their social transition to their preferred identity; researcher scaffolding supported the video messages. Children who viewed the Jazz video had: (a) greater understanding of transgender identities and (b) no overall differences in gender essentialism, but (c) lower gender essentialism on three specific measures (gender immutability, innate toy behaviours and innate preferences). Also, gender essentialism was lower in older versus younger children. In this study, a direct, realistic story was the only effective means of teaching children about transgender identities and reducing belief in gender immutability. Thus, stories can be a way to teach children about the social world and change essentialist beliefs, but the impact may be limited and greatly affected by features of the story.

The Association Between Sexual Violence and Suicidal Ideation Among Transgender Women and the Role of Gender-Affirming Healthcare Providers in Seven Urban Areas in the United States, 2019 to 2020

Transgender women are disproportionately affected by sexual violence and corresponding mental health sequelae; however, many do not access healthcare due to experiences with transphobia. This analysis evaluated the association between sexual violence and suicidal ideation and the moderating effect of having a healthcare provider (HCP) with whom transgender women were comfortable discussing gender-related issues ("gender-affirming HCP"). We analyzed cross-sectional data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance among Transgender Women (NHBS-Trans). Transgender women were recruited using respondent-driven sampling from seven urban areas from 2019 to 2020 and participated in an HIV biobehavioral survey. This analysis was restricted to transgender women who visited a HCP in the past 12 months ("healthcare-seeking transgender women" [HSTW]) (N = 1,489). Log-linked Poisson regression models provided adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to estimate the association between sexual violence and suicidal ideation in the past 12 months. The interaction between sexual violence and having a gender-affirming HCP was statistically significant (p-value = .034). Among 1,489 HSTW, 225 (15.1%) experienced sexual violence and 261 (17.5%) reported suicidal ideation; 1,203 (80.8%) reported having a gender-affirming HCP. Sexual violence was associated with suicidal ideation (aPR = 2.65, 95% CI [2.08, 3.38]); the association was notably higher among those who did not have a gender-affirming HCP (aPR = 3.61, [2.17, 6.02]) than among those who did (aPR = 1.87, [1.48, 2.37]). Eliminating transphobia and promoting trauma- and violence-informed approaches in healthcare are necessary for sexual violence and suicide prevention among HSTW.

White American transgender adults' retrospective reports on the social and contextual aspects of their gender identity development

A growing body of research has attended to the experiences of transgender and gender non-conforming (TGN) youth's gender identity development. However, practical and ethical concerns have impeded our ability to understand the experiences of TGN youth. Thus, the aim of this study was to utilize one-on-one semi-structured interviews to explore White American TGN adults' (N = 15) retrospective accounts of their gender identity development in childhood and adolescence. Findings demonstrate considerable heterogeneity in TGN adults' retrospective accounts of their gender identity development. However, TGN adults consistently highlighted the role of social (e.g. friends, family and teachers) and contextual (e.g. online, offline, educational and geographical) factors in their gender identity journeys. This study provides new insight into the role of social and contextual factors in TGN adults' retrospective accounts of their gender identity development, demonstrating the importance of continuing to examine these factors in gender diversity research.

The Role of Internalized Transphobia, Loneliness, and Social Support in the Psychological Well-Being of a Group of Italian Transgender and Gender Non-Conforming Youths

Although transgender and gender non-conforming (TGNC) youth represent a highly resilient community capable of successfully overcoming adverse life circumstances, they still face social stigma that negatively impacts their health, being at risk of developing negative feelings toward their own TGNC identity (i.e., internalized transphobia). A poorly investigated dimension in TGNC health research is perceived loneliness. Thus, within the minority stress theory, the present study aimed to investigate the mediating role of loneliness and the moderating role of social support in the relationship between internalized transphobia and psychological well-being among 79 Italian TGNC youths aged 18 to 30-years-old who participated in an online survey. The main results show that loneliness partially mediated the relationship between internalized transphobia and psychological well-being. In addition, social support emerged as a significant moderator, as the impact of internalized transphobia on psychological well-being decreased at moderate and high levels of social support, but not at low levels. The findings have significant implications for clinical practice and psychosocial interventions to reduce the impact of internalized stigma and stress on psychological health.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

"Transsexuality" and gender ratio in Poland: A case study on the East/West dichotomy

The article investigates scientific and journalistic discourses around differences in gender ratio among trans persons. The disparity between Poland and many other countries that was first noted in the 1980s was repeatedly associated with the different gender politics in the capitalist West and the (post) state-socialist East. Using Foucauldian methodology, the article claims that this discourse was constructed such that Poland's ratio-and consequently Poland's gender order-would always appear problematic, while Western countries were considered an invisible standard. Discourses around this ratio elucidate the role of heteronormativity and biological essentialism in the construction of the category of "transsexuality" in state-socialist Poland. The analysis also reveals that chronologies of LGBT and feminist movements had direct consequences for the theoretical and cultural spaces of trans identities.

Advances in Research on Adolescent Suicide and a High Priority Agenda for Future Research

Suicide is the second leading cause of death for adolescents in the United States, yet remarkably little is known regarding risk factors for suicidal thoughts and behaviors (STBs), relatively few federal grants and scientific publications focus on STBs, and few evidence-based approaches to prevent or treat STBs are available. This "decade in review" article discusses five domains of recent empirical findings that span biological, environmental, and contextual systems and can guide future research in this high priority area: (1) the role of the central nervous system; (2) physiological risk factors, including the peripheral nervous system; (3) proximal acute stress responses; (4) novel behavioral and psychological risk factors; and (5) broader societal factors impacting diverse populations and several additional nascent areas worthy of further investigation.

Unmet Healthcare Need Due to Cost Concerns among U.S. Transgender and Gender-Expansive Adults: Results from a National Survey

This study examines past-year unmet healthcare need due to cost experienced by transgender and gender-expansive (TGE) adults in the United States in the context of the Patient Protection and Affordable Care Act (ACA). It also aims to estimate the importance of having health insurance among TGE Americans (transgender men, transgender women, nonbinary/genderqueer people, and cross-dressers). Data were from the 2015 U.S. Transgender Survey (N = 19,157 adults, aged 25 to 64 years). Multivariable logistic regression models were used to determine the adjusted odds ratios (AOR) and 95 percent confidence intervals (CI) of TGE individuals' past-year unmet healthcare need due to cost. Although the majority (86.8 percent) reported seeing a doctor or healthcare provider in the past year, 32.1 percent reported past-year unmet healthcare need due to cost. One in six respondents (17.1 percent) was uninsured and almost one-third (29.8 percent) were at/near poverty. The prevalence of unmet healthcare need was greater among the uninsured (65.1 percent) than among the insured (25.2 percent). Compared with transgender women, nonbinary/genderqueer people (AOR = 1.31, 95% CI [1.18, 1.46]) and transgender men (AOR = 1.30, 95% CI [1.18, 1.42]) had greater odds of unmet healthcare need due to cost. Social workers can lobby to fully enact the ACA by underscoring affordability and availability as important dimensions of healthcare access for TGE populations.

Sociodemographic Characteristics, Gender Identification, and Gender Affirmation Pathways in Transgender People: A Survey Study in Chile

Understanding the internal diversity of transgender communities is essential for developing optimal, inclusive policies and service provision. To date, research on this topic remains scarce in Chile. We conducted a survey study describing sociodemographic characteristics (age, sex assigned at birth, onset age, nationality, education, sex work, having a partner, having children, sexual orientation, religiousness, gender identification, and gender affirmation pathways). A snowball sample of 377 self-identified transgender adults living in Chile (Mage = 31.88, rangeage = 18-67) was collected for the purpose of this study. According to their sex assigned at birth, 139 participants were female and 238 male. Results revealed that sex assigned at birth was significantly associated with almost all the sociodemographic variables. Eight gender self-identification categories were obtained based on self-declaration. These gender identification categories varied according to sex assigned at birth. Finally, four patterns (clusters) of gender affirmative actions were identified among participants. These patterns indicated that the longer the gender affirmation pathway time, the greater the invasiveness level of the medical procedures used. Sex assigned at birth moderated the association between gender affirmation pathways and gender identity categories. Results were discussed highlighting the heterogeneity found in terms of sociodemographic characteristics, gender identification, and gender affirmation pathways.

Prevalence of Gender Dysphoria in Southern Brazil: A Retrospective Study

To ensure that public health services provide comprehensive and inclusive health care to the general population, it is important for countries to estimate how many of their citizens experience gender dysphoria and wish to receive specialized hormone treatment or gender-affirming surgery. The aim of this study was to estimate the prevalence of individuals with gender dysphoria seeking transgender health care in a public teaching hospital in southern Brazil. In this retrospective follow-up study, we analyzed the medical records and sociodemographic data of individuals aged > 15 years living in Rio Grande do Sul, Brazil, that enrolled in a specialized program to receive hormone therapy and gender-affirming surgery between 2000 and 2018. This study is the first to attempt estimating the prevalence of gender dysphoria in Rio Grande do Sul; it describes novel data on the clinical profile of individuals with gender dysphoria treated in a public hospital specialized in providing transgender health care. Prevalence estimates were calculated based on statewide annual population data in the study period. Of 934 identified individuals, 776 (601 trans women and 175 trans men) were included in this study. The overall prevalence of individuals with gender dysphoria was 9.3 per 100,000 individuals (95% CI: 8.6 to 9.8). Meanwhile, there were 15 trans women per 100,000 people (95% CI: 14 to 16) and 4.1 trans men per 100,000 people (95% CI: 3.5 to 4.8). There was a progressive increase in the number of people seeking hormone therapy and gender-affirming surgery during the study period. Future research is needed to determine the size of the trans population in other regions of Brazil and to expand the knowledge regarding gender dysphoria to allow for the development of effective public policies for people with gender dysphoria.

Ask Again: Including Gender Identity in Longitudinal Studies of Aging

Information on transgender people's health, and especially their experiences of aging, is lacking, including from major longitudinal studies of aging like the Health and Retirement Study and its sister studies in the Gateway to Global Aging Data project. This paper surveys the state of gender data collection among major longitudinal studies and finds that all but one fail to collect adequate information on participants' gender to determine participants' gender identities. It identifies the unique challenges that population-wide longitudinal data collection poses to current best practices for identifying transgender survey participants and proposes a modified "two-question model": one question for sex assigned at birth and a second for gender identity, both of which offer 3 responses.

Epidemiological considerations in transgender health: A systematic review with focus on higher quality data

Background: High quality data pertaining to the size of the transgender and gender diverse (TGD) population are scant, however, several recently published studies may provide more reliable contemporary estimates. Aims: To summarize the estimated number and proportion of TGD individuals overall and across age groups, based on most accurate data. Methods: This systematic review focused on recent studies (published from 2009 through 2019) that utilized sound methodology in assessing the proportion of TGD people in the general population. Publications were included if they used clear definitions of TGD status, and calculated proportions based on a well-defined sampling frame. Nineteen eligible publications represented two broad categories of studies: those that used data from large health care systems; and those that identified TGD individuals from population surveys. Results: Among health system-based studies, TGD persons were identified using relevant diagnostic codes or clinical notes. The proportions of individuals with a TGD-relevant diagnosis or other recorded evidence ranged between 17 and 33 per 100,000 enrollees. In population surveys TGD status was ascertained based on self-report with either narrow or broad definitions. The survey-based estimates were orders of magnitude higher and consistent across studies using similar definitions. When the surveys specifically inquired about 'transgender' identity, the estimates ranged from 0.3% to 0.5% among adults, and from 1.2% to 2.7% among children and adolescents. When the definition was expanded to include broader manifestations of 'gender diversity', the corresponding proportions increased to 0.5-4.5% among adults and 2.5-8.4% among children and adolescents. Upward temporal trends in the proportion of TGD people were consistently observed. Conclusions: Current data indicate that people who self-identify as TGD represent a sizable and increasing proportion of the general population. This proportion may differ, depending on inclusion criteria, age, and geographic location, but well-conducted studies of similar type and design tend to produce comparable results.

A deviation too many? Healthcare professionals' knowledge and attitudes concerning patients with intellectual disability disrupting norms regarding sexual orientation and/or gender identity

BACKGROUND

People with intellectual disability (ID) have few role models for sexual expression and behaviour, and those who identify as LGBTQ experience dual marginalization. The aim of this study is to explore knowledge and attitudes concerning patients with both ID and norm-breaking sexuality and/or gender identity among healthcare professionals in habilitation centres.

METHOD

Data were collected from four focus group interviews that included 19 healthcare professionals from child and adult teams at two Swedish habilitation centres. Data were analysed using thematic analysis.

RESULTS

Three themes were identified as follows: heteronormative treatment in health care, barriers for inclusion and possibilities for inclusion.

CONCLUSIONS

Norm-breaking sexuality and gender identity are still relatively invisible in habilitation centres. People with ID are still predominately desexualized and perceptions regarding their sexuality are lagging behind the rest of society. Conditions that allow for more LGBTQ-affirmative practice were described by the teams that have undergone LGBTQ training.

Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening

Metoidioplasty denotes the creation of a neophallus out of the hormonally hypertrophied clitoris. Construction of an esthetically acceptable male-like genitalia while enabling micturition in standing position are the primary goals. Herein, we aim to review the literature regarding masculinizing gender-affirming genital surgery in the form of metoidioplasty, focusing on the steps related to urethral lengthening and reconstruction, and describe the authors' preferred surgical technique. Clitoral release, division of the urethral plate, native urethral lengthening with anterior vaginal wall flap, and neourethral tubularization using a combination of buccal mucosa graft and labia minora flap(s) seem to provide the best result in terms of urinary outcomes. This is reflected in a greater urethral length, higher probability of standing micturition, and lower incidence of fistula. Urethral complications, which can be encountered in up to 15% of the patients, may necessitate additional procedures. Some of the studies have reported successful penetrative intercourse following metoidioplasty. Case series about different metoidioplasty techniques do not allow head-to-head comparison due to non-standardized reporting and outcome assessment. Metoidioplasty can be offered to transgender men with sufficiently hypertrophied clitoris who wish to avoid a complicated, multistage, flap-based total phalloplasty, or for those individuals considering phalloplasty at a later date.

Barriers to Mental Health Care for Transgender and Gender-Nonconforming Adults: A Systematic Literature Review

Contemporary research suggests that transgender and gender-nonconforming (TGNC) adults encounter formidable barriers to health care, including access to quality therapeutic interventions. This systematic review is one of the first to specifically explore obstacles to TGNC mental health care. A rigorous literature review identified eight relevant studies: six qualitative designs and two quantitative designs. Thematic synthesis revealed three major barriers to care and five corresponding subthemes: (1) personal concerns, involving fear of being pathologized or stereotyped and an objection to common therapeutic practices; (2) incompetent mental health professionals, including those who are unknowledgeable, unnuanced, and unsupportive; and (3) affordability factors. Results indicate an acute need for practitioner training to ensure the psychological well-being of TGNC clients.

Women Publishing in American Psychological Association Journals: A Gender Analysis of Six Decades

Despite recent advances, gender inequality persists in many scientific fields, and Psychology is not alien to this phenomenon. This study presents the evolution of gender composition in American Psychological Association publications in the past six decades, from 1963 to 2016. Longitudinal analysis revealed an important change: women rose from a tiny 12% to 14% in the 1960s to almost gender parity in the last decade (2010s). The pattern of collaboration (coauthorship) shows that women tend to be slightly overrepresented as first author and underrepresented as the last or senior author. In the last two decades, women outnumber men as "new" American Psychological Association authors (authors who publish for the first time in an American Psychological Association journal). These features and the fact that men's publications tend to encompass a much wider range of years suggest that age may play a role in the gender composition of American Psychological Association contributors.

Health Care Experiences of Transgender Binary and Nonbinary University Students

An increasing number of young adults identify with nonbinary gender identities. Yet health providers and therapists often lack understanding of such identities. In this mixed-methods study of 506 transgender undergraduate and graduate students, most of whom (75%) had nonbinary gender identities, we aimed to understand participants’ mental health and health care experiences, and factors related to misgendering and less affirming treatment by providers. Eighty-five percent of participants reported mental health challenges, and named fear of violence and nonsupport as distal stressors. Experiences with therapists and health providers were mixed. Salient features of negative interactions were invalidation, avoidance, or overemphasis in regard to participants’ nonbinary identities. Participants viewed counseling services as more affirming than health services. Nonbinary students reported more misgendering by therapists and health providers, and less trans-affirming care by health service providers, compared to binary students. Undergraduate students reported more misgendering by therapists and health providers than graduate students.

A Preliminary Examination of the Association between Adolescent Gender Nonconformity and Suicidal Thoughts and Behaviors

Suicidal thoughts and behaviors are a significant health concern for adolescents. Extant research suggests that sexual and gender minority adolescents are a vulnerable population at elevated risk for suicidal thoughts and behaviors, yet to date few studies have examined the unique associations between adolescent gender nonconformity and suicide risk. This study examined data from the Youth Risk Behavior Surveillance Survey (n = 7730) to estimate the association between gender nonconformity and high school-aged adolescents' likelihood of endorsing four distinct suicide outcomes: suicidal ideation, suicide plans, any suicide attempts, and single vs. multiple suicide attempts. Multivariate logistic regression analyses were utilized to control for other known risk factors for suicidal thoughts and behaviors, including age, sex, sexual minority status, depression symptoms, and suicidal ideation. Results revealed that gender nonconformity was significantly associated with higher odds of reporting suicidal ideation, suicide plans, and multiple suicide attempts in the past year above and beyond other known risk factors. Gender nonconformity is an understudied vulnerability factor that should be taken into consideration by researchers and clinicians seeking to understand adolescents' risk for suicidal thoughts and behaviors.

HIV Prevalence and Risk Behaviors in Male to Female (MTF) Transgender Persons in Tijuana, Mexico

Compared to HIV research on men who have sex with men, less is known about the risks and vulnerabilities for HIV among Male to Female (MTF) transgender persons, particularly in different geographic regions like Mexico. In Tijuana, Mexico, a border city experiencing a dynamic HIV epidemic, no precedent data exists on the MTF transgender population. Our aims were to estimate HIV prevalence and examine the behaviors and characteristics of the population. We conducted a cross-sectional study of 100 MTF transgender persons recruited through time location sampling in 2012. Participants underwent interviewer-administered (paper and pen) surveys and rapid tests for HIV. Descriptive univariate analyses were conducted on various factors, including sociodemographics, substance use, accessing social services (requested vs. received), stigma, and sex behaviors. A total of 22% tested positive for HIV, a prevalence higher than other key populations at risk for HIV in Tijuana.

Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples

BACKGROUND

Transgender individuals have a gender identity that differs from the sex they were assigned at birth. The population size of transgender individuals in the United States is not well-known, in part because official records, including the US Census, do not include data on gender identity. Population surveys today more often collect transgender-inclusive gender-identity data, and secular trends in culture and the media have created a somewhat more favorable environment for transgender people.

OBJECTIVES

To estimate the current population size of transgender individuals in the United States and evaluate any trend over time.

SEARCH METHODS

In June and July 2016, we searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and Web of Science for national surveys, as well as "gray" literature, through an Internet search. We limited the search to 2006 through 2016.

SELECTION CRITERIA

We selected population-based surveys that used probability sampling and included self-reported transgender-identity data.

DATA COLLECTION AND ANALYSIS

We used random-effects meta-analysis to pool eligible surveys and used meta-regression to address our hypothesis that the transgender population size estimate would increase over time. We used subsample and leave-one-out analysis to assess for bias.

MAIN RESULTS

Our meta-regression model, based on 12 surveys covering 2007 to 2015, explained 62.5% of model heterogeneity, with a significant effect for each unit increase in survey year (F = 17.122; df = 1,10; b = 0.026%; P = .002). Extrapolating these results to 2016 suggested a current US population size of 390 adults per 100 000, or almost 1 million adults nationally. This estimate may be more indicative for younger adults, who represented more than 50% of the respondents in our analysis.

AUTHORS' CONCLUSIONS

Future national surveys are likely to observe higher numbers of transgender people. The large variety in questions used to ask about transgender identity may account for residual heterogeneity in our models. Public health implications. Under- or nonrepresentation of transgender individuals in population surveys is a barrier to understanding social determinants and health disparities faced by this population. We recommend using standardized questions to identify respondents with transgender and nonbinary gender identities, which will allow a more accurate population size estimate.

Providing Competent and Affirming Services for Transgender and Gender Nonconforming Older Adults

Despite the growing visibility and acceptance of transgender and gender nonconforming (TGNC) individuals, TGNC older adults experience many barriers in accessing competent and affirming health and social services due to anti-TGNC prejudice, discrimination, and lack of competent healthcare training on the part of healthcare workers. Clinical gerontologists and geriatricians will likely encounter TGNC adults in their practice given population aging and greater numbers of TGNC people who are living in their affirmed gender identities. The American Psychological Association recently published its Guidelines for Psychological Practice with Transgender and Gender Nonconforming People, which document the unique needs of TGNC individuals and outlines approaches for competent and affirming service provision (APA, 2015). We interpret these Guidelines using a gerontological lens to elucidate specific issues faced by the TGNC older adult along with the practice and policy implications for this population.

The Social Costs of Gender Nonconformity for Transgender Adults: Implications for Discrimination and Health

Research suggests that transgender people face high levels of discrimination in society, which may contribute to their disproportionate risk for poor health. However, little is known about whether gender nonconformity, as a visible marker of one's stigmatized status as a transgender individual, heightens trans people's experiences with discrimination and, in turn, their health. Using data from the largest survey of transgender adults in the United States, the National Transgender Discrimination Survey (N = 4,115), we examine the associations among gender nonconformity, transphobic discrimination, and health-harming behaviors (i.e., attempted suicide, drug/alcohol abuse, and smoking). The results suggest that gender nonconforming trans people face more discrimination and, in turn, are more likely to engage in health-harming behaviors than trans people who are gender conforming. Our findings highlight the important role of gender nonconformity in the social experiences and well-being of transgender people.

Gender identification and sex reassignment surgery in the trans population: a survey study in France

Drawing from controversies between medical, legal, and associative actors about the obligation of sex reassignment surgeries (SRS) for people who intend to change their civil status, this article discusses the role that medical procedures, and particularly SRS, play in contemporary gender identifications and transition pathways in France. In 2010, the French National Institute of Health and Medical Research conducted a national survey in order to study the sociodemographic characteristics, access to medical, and psychological care, and state of health among trans individuals. After a long period of ethnographic work during which a partnership was established with trans actors to map the social, medical, and political landscape of trans communities, a questionnaire was developed and distributed between July and October 2010 in collaboration with most of the trans organizations and public and private health professionals operating in France. Overall, 381 self-identified trans individuals returned the anonymous self-administered questionnaire. The results highlighted the heterogeneity of the trans population, whose definition cannot be reduced to a group of individuals undergoing standardized hormonal treatments and SRS. Two central indicators, sex assigned at birth and gender self-identification, enabled us to describe and analyze different medical and legal pathways with a particular focus on SRS, which is often compulsory for a change of civil status in France. Although SRS remains an important factor in an individual's subjective evaluation of the success of the transition pathway, its practice varies depending on one's sex assigned at birth and gender identification.

Gender Dysphoria and Co-Occurring Autism Spectrum Disorders: Review, Case Examples, and Treatment Considerations

PURPOSE

Transgender and gender nonconforming people who fulfill diagnostic criteria for autism spectrum disorders (ASDs) often present to mental health providers with concerns that are distinct from those without ASDs. Gender Dysphoria (GD) and ASDs have been proposed to share etiologic mechanisms and there is evidence that ASDs may be more common in transgender and gender nonconforming people. We explore the impact of ASD characteristics on individual gender identity, expression, and the process of psychotherapy.

METHOD

The authors present two case studies of high-functioning individuals with ASD and GD diagnoses.

RESULTS

The limited ability to articulate an inner experience, deficits in Theory of Mind (ToM), along with the intolerance of ambiguity as a manifestation of the cognitive rigidity characteristic of ASDs, may present special difficulties to gender identity formation and consolidation and create challenges in psychotherapy.

CONCLUSIONS

The authors suggest that ASDs do not preclude gender transition and that individuals with high-functioning ASDs are capable of making informed decisions regarding their medical care and life choices. The authors also consider possible challenges and suggest techniques for assisting such clients in exploring their gender identities.