Memo outlining evidence for change for gender identity disorder in the DSM-5

What's on the Gay (Legal) Agenda? An Analysis of Press Releases From LGBT Legal Advocacy Organizations, 2010-2019

What's on the gay (legal) agenda? This study addresses this question by examining the press releases of national LGBT legal advocacy organizations in response to both new opportunities, after decisions such as U.S. v. Windsor (2013) and Obergefell v. Hodges (2015), and significant challenges such as the election of Donald Trump in 2016 and his subsequent conservative judicial appointments. Using original data from more than 2,800 press releases filed by the largest LGBT legal advocacy organizations from 2010 to 2019, we analyze the LGBT legal agenda and explore how it evolved throughout this period in reaction to changes in the legal opportunity structure. We find that LGBT legal advocacy organizations are strategic and adapt their agendas to shifts in their legal opportunities to achieve social movement goals. Specifically, we find that after marriage equality was achieved, significant shifts in the legal opportunity structure, including conservative countermobilization and new cultural and legal frames, placed transgender rights at the top of the LGBT legal agenda. These findings shed light on the politics of LGBT legal advocacy organizations, provide insight into LGBT politics after Obergefell, and contribute to our understanding of how legal advocacy organizations respond to changing legal opportunities in social movements.

Dimensional approach to gender dysphoria in Nigeria: Association with socio-demographic and psycho-sexual variables

Background

Recent changes across the world with respect to gender transitioning of children and adolescents have generated a bio-psycho-socio-cultural discourse among interest groups.

Aim

This study sought to examine gender dysphoric symptoms among adolescents and young persons in an African population, using a dimensional approach.

Method

A total of 747 primary/secondary school and university students aged 10-24 years were studied using the 27-item Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA). Participants were divided into early, mid- and late adolescents. The composite and domain scores were calculated using the criteria described by Deogracias, and comparison of the median scores was done using Mann-Whitney U-test and Kruskal-Wallis test as appropriate. Dunnett's post-hoc test was used for pairwise comparisons.

Results

The prevalence of self-identified transgender and self-reported non-heterosexuals was 0.9% (95%CI: 0.36-1.92) and 18.6% (15.85-21.59), respectively. The participants as a group scored 4.56 out of a possible 5 on the gender dysphoria scale, indicating less gender dysphoric symptoms in this cohort. However, participants in mid- and late adolescents had significantly lower scores when compared with early adolescents (P = 0.009). Self-reported transgender had significantly lower scores in the social (P = 0.001) and socio-legal (P < 0.001) indicators of the scale.

Conclusion

The findings of this study, although, preliminary demonstrated less gender dysphoric symptoms in this cohort of Nigerian adolescents and young adults compared to the Western population. Nevertheless, some degree of GD was noticed, revealing that this condition is existent in our society.

Prevalence and Comorbidity of Gender Dysphoria in Taiwan, 2010-2019

Gender dysphoria (GD) is a condition in which a person exhibits marked incongruence between their expressed or experienced gender and their sex assigned at birth. The last survey of individuals with GD in Taiwan was conducted approximately 10 years ago. In this study, we investigated the prevalence of GD in Taiwan within the last 10 years as well as comorbidities. A retrospective medical record review was performed for all patients in the database of the Health and Welfare Data Science Center covered by National Health Insurance in Taiwan from January 2010 until December 2019. The study population of persons with GD was defined as individuals who had been diagnosed with transsexualism (transgender or transsexual) or gender identity disorders. Our review found case numbers and prevalence of GD in 2019 were about twice that of patients in 2010 for both assigned males and assigned females at birth. Case numbers for 2010 versus 2019 were 440 versus 867 for assigned males at birth, and 189 versus 386 for assigned females at birth. The 1-year prevalence for 2010 versus 2019 was 3.8/100,000 versus 7.4/100,000 for assigned males at birth, and 1.6/100,000 versus 3.2/100,000 for assigned females at birth. Comorbidities of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and psychosis were more likely in children with GD younger than 12 years of age; comorbid depression was more likely in adolescents and adults with GD. Improvements in social and mental health support should be provided to help address these comorbidities of ADHD, ASD, and depression among individuals with GD.

Is it really about freedom of thought?

This opinion piece responds to Marcus Evans's 'Freedom to Think' regarding treating adolescents diagnosed with gender dysphoria (DSM)/gender incongruence (ICD). Evans notes not everything is known about GD/GI, particularly its 'causes'. Although correct, he presents this fact as a rationale for delaying treatment for all children presenting with GD/GI symptoms. However, Marcus does not specify how long such prolonged evaluations should last nor does he have much of an evidence base to support his recommendation. This author believes delaying treatment for GD/GI adolescents who need it for the benefit of children who 'aren't really' transgender is an ethically troubling issue.

Models of care for gender dysphoria in young persons: How Psychiatry lost and is finding its voice

Globally, models of care for young persons with gender dysphoria differ across jurisdictions. Historically, developed countries have utilised the medical approach. More recently, broader models that place a greater emphasis on psychological interventions are emerging. This piece utilizes the Australian experience to compare models of care for gender dysphoria. Reflecting on the relative passivity of Psychiatry to date, historical reasons for this silence are explored. As relative experts in relationship dynamics and key bearers of the history of sexual health diagnoses, it is proposed that Psychiatrists have both the requisite skills and responsibility to share reflective lessons with other medical specialties in this space. Only by doing so may they provide appropriate care and treatment for young persons suffering mental distress due to gender incongruence.

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.

Informed Consent or Scare Tactics? A Response to Levine et al.'s "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults"

This responds to "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults" by Levine et al., part of a small but growing, critical response to contemporary treatments of gender dysphoric/incongruent (GD/GI) children and adolescents. This author, while disagreeing with Levine et al. and other critics, hopes that with dialogue, research and engagement with the wider world, needs of all children, adolescents and young adults-those who have GD/GI and those who may not-will be best served. Critics of gender affirming treatments cite growing numbers of cases, "low level of evidence" supporting treatment, irreversible side effects and expressing regrets as reasons to oppose gender affirmative treatments. Although sharing similar concerns, the author does not conclude treatments should not be offered when appropriate. The critics' alternative reads as "just talk to the young people and find out what is really bothering them." Lacking empirical evidence for that approach does not appear to trouble them.Levine et al.'s caricature of informed consent, which this author parodies, would dissuade anyone from treatment. Their approach does not appear to be written for purposes of engaging frontline clinicians with the aim of improving treatment. Instead, they read as appeals to third parties unfamiliar with the clinical presentations of these children-parents, caretakers courts, legislatures, state health departments and national health care systems-to discourage treatments from proceeding. This impression is further buttressed by a declaration of financial support from The Society for Empirical-Based Gender Medicine, a small group of outliers from mainstream clinicians treating minors with GD/GI who present as "truth-speaking" experts regarding "facts" being ignored, elided over or perhaps even covered up by the mainstream.The author concludes by noting that clinicians who advocate for delaying treatment to GD/GI minors who need and may benefit from it to "protect" those who "aren't really" transgender is an ethically troubling issue. In other words, "first, do no harm" is a sword that cuts two ways.

Medicine as constraint: Assessing the barriers to gender-affirming care

In this commentary, we describe the way in which science has been used to constrain transgender peoples’ access to gender-affirming care. The required diagnosis of gender dysphoria is rooted in both the historical assumption that psychological distress is an inherent aspect of being transgender and the incorrect notion that gender-affirming care is a panacea for the mental health issues that transgender people may experience, regardless of whether these mental health issues are related to their being transgender. We provide recommendations for how to address these barriers to care moving forward.

Validity of the Gender Dysphoria diagnosis and incidence trends in Sweden: a nationwide register study

The aim of this study was to examine the validity of the Gender Dysphoria (GD) diagnoses in the Swedish National Patient Register (NPR), to discuss different register-based definitions of GD and to investigate incidence trends. We collected data on all individuals with registered GD diagnoses between 2001 and 2016 as well as data on the coverage in the NPR. We regarded gender confirming medical intervention (GCMI) as one proxy for a clinically valid diagnosis and calculated the positive predictive value (PPV) for receiving GCMI for increasing number of registered GD diagnoses. We assessed crude and coverage-adjusted time trends of GD during 2004-2015 with a Poisson regression, using assigned sex and age as interaction terms. The PPV for receiving GCMI was 68% for ≥ 1 and 79% for ≥ 4 GD-diagnoses. The incidence of GD was on average 35% higher with the definition of ≥ 1 compared to the definition of ≥ 4 diagnoses. The incidence of GD, defined as ≥ 4 diagnoses increased significantly during the study period and mostly in the age categories 10-17 and 18-30 years, even after adjusting for register coverage. We concluded that the validity of a single ICD code denoting clinical GD in the Swedish NPR can be questioned. For future research, we propose to carefully weight the advantages and disadvantages of different register-based definitions according to the individual study's needs, the time periods involved and the age-groups under study.

Lifetime prevalence of suicidal ideation and suicidal behaviors in gender non-conforming youths: a meta-analysis

Gender identity represents a topic of growing interest in mental health research. People with non-conforming gender identity are prone to suffer from stigmatization and bullying and often present psychiatric issues, which may in turn lead to a high prevalence of suicidal ideation and behaviors. The present meta-analysis aimed to estimate the prevalence of suicidal ideation and suicidal behaviors in gender non-conforming children, adolescents and young adults. A systematic search was performed in Web of Science and PsycINFO from inception to December 2018. We selected cross-sectional and cohort studies including youths (up to 25 years) with a diagnosis confirmed by a clinician according to international classifications, or after a direct interview with a peer. A random-effects meta-analysis was computed for the following outcomes: non-suicidal self-injury (NSSI), suicidal ideation and suicide attempts. Overall, we found a mean prevalence of NSSI of 28.2% (9 studies, 3057 participants, 95% CI 14.8-47.1). A similar prevalence (28%) was found for suicidal ideation (6 studies, 2249 participants, 95% CI 15-46.3), while the prevalence of suicide attempts was 14.8% (5 studies, 1039 participants, 95% CI 7.8-26.3). Subgroup analyses revealed no significant differences according to biological sex. Given the prevalence of suicidal behaviors in gender non-conforming youths, it appears desirable to implement therapeutic and support strategies for this population. Moreover, educational interventions directed to parents, teachers, mental health professionals and general community should be promoted to struggle against stigma and social isolation, factors that may contribute to increasing the risk of suicidal behaviors.

Receipt of evidence-based alcohol-related care in a national sample of transgender patients with unhealthy alcohol use: Overall and relative to non-transgender patients

BACKGROUND/OBJECTIVE

Evidence-based alcohol-related care-brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)-should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use.

METHODS

We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0-14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0-365 days following screening), and filled prescriptions for medications to treat AUD (documented 0-365 days following screening) for transgender patients, and compared to that of non-transgender patients.

RESULTS

Among transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2-78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7-17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1-20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98-1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12-1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06-1.28, p = 0.002).

CONCLUSIONS

Findings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall.

Sexual health after vaginoplasty: A systematic review

BACKGROUND

Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.

OBJECTIVES

To investigate sexual health after gender-affirming vaginoplasty for TGD patients.

DATA SOURCES

MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design.

METHODS

We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids.

RESULTS

Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.

CONCLUSIONS

The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

A Follow-Up Study of Boys With Gender Identity Disorder

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.

How gender dysphoria and incongruence became medical diagnoses – a historical review

This article is a historical review of the medical and psychiatric diagnoses associated with transgender people across epochs. Ancient Greek and Roman writings already mention gender change. Before a diagnosis even existed, historical documents described the lives of numerous people whom we would consider transgender today. The development of medical classifications took off in the nineteenth century, driven by the blooming of natural sciences. In the nineteenth century, most authors conflated questions of sexual orientation and gender. For example, the psychiatrist Krafft-Ebing reported cases of transgender people but understood them as paranoia, or as the extreme degree of severity in a dimension of sexual inversion. In the early 1900s, doctors such as Magnus Hirschfeld first distinguished homosexual and transgender behaviour. The usual term for transgender people was transvestite, before Harry Benjamin generalised the term transsexual in the mid-20th century. The term transgender became common in the 1970s. This article details the evolution of diagnoses for transgender people from DSM-III and ICD-10 to DSM-5 and ICD-11.

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

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

Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists

(Copyright © William Byne et al. 2018; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.).

Mental Health Care for LGBT Youths

Lesbian, gay, bisexual, and transgender (LGBT) youths comprise a diverse population with unique developmental experiences and needs. Many experience some form of anti-LGBT stigma. Although most LGBT youths cope well and are free from mental illness, they are at increased risk for a number of psychiatric and other health problems compared with the general population. These problems include depression, anxiety, suicidality, tobacco and substance use, and disordered eating. These disorders are significant sources of morbidity and mortality and are risk factors for other health problems, including HIV and other sexually transmitted infections. Preliminary evidence suggests the same is true for gender dysphoric youths. The minority stress hypothesis holds that exposure to LGBT-specific stigma causes these disparities among LGBT youth. During the past decade, increasing attention has been devoted to developing evidence-based practice guidelines to address the mental health needs of LGBT youths, with an emphasis on core clinical competencies for practitioners working with this population. This review addresses key principles for mental health promotion and care of LGBT youths. Key resources for clinicians and two clinical vignettes are included.

The phenomenology of gender dysphoria in adults: A systematic review and meta-synthesis

Gender dysphoria is distress due to a discrepancy between one's assigned gender and gender identity. Adults who wish to access gender clinics are assessed to ensure they meet the diagnostic criteria for gender dysphoria. Therefore, the definition of gender dysphoria has a significant impact on the lives of individuals who wish to undergo physical gender transition. This systematic review aimed to identify and synthesize all existing qualitative research literature about the lived experience of gender dysphoria in adults. A pre-planned systematic search identified 1491 papers, with 20 of those meeting full inclusion criteria, and a quality assessment of each paper was conducted. Data pertaining to the lived experience of gender dysphoria were extracted from each paper and a meta-ethnographic synthesis was conducted. Four overarching concepts were identified; distress due to dissonance of assigned and experienced gender; interface of assigned gender, gender identity and society; social consequences of gender identity; internal processing of rejection, and transphobia. A key finding was the reciprocal relationship between an individual's feelings about their gender and societal responses to transgender people. Other subthemes contributing to distress were misgendering, mismatch between gender identity and societal expectations, and hypervigilance for transphobia.

•

A systematic review of all papers on the lived experience of gender dysphoria

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Twenty papers with 1606 participants were included in a meta-ethnographic synthesis.

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Distress was due to gender and sex incongruence, as well as social factors.

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Results give new insights into the relationships between factors causing distress.

The Misuse of Gender Dysphoria: Toward Greater Conceptual Clarity in Transgender Health

The notion of gender dysphoria is central to transgender health care but is inconsistently used in the clinical literature. Clinicians who work in transgender health must understand the difference between the diagnosis of Gender Dysphoria as defined and described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the notion of this term as used to assess eligibility for transition-related interventions such as hormone-replacement therapy and surgery. Unnecessary diagnoses due to the belief that a diagnosis is clinically required to access transition-related care can contribute to stigma and discrimination toward trans individuals.

Commentary: The Problems of Grouping All Adversity Into a Special Populations Label

"Special populations" refer to groups of people whose needs are not fully addressed by traditional health services delivery. Greater access to these services, or tailored services, must be provided to reduce inequities in physical and mental health-care systems. Many different groups have been identified as special populations. We comment on controversies regarding the use of the term special populations in health practice and policy. Applicable conceptual issues include intersectionality, unitization, definitional drawbacks, and looping effects. There is a need to make clear the challenges posed by use of this term (e.g., discrimination, workability). An approach that acknowledges the diversity of groups and accommodates them where necessary without discrimination and unequal treatment is needed.

"Diagnosing" Gender? Categorizing Gender-Identity Variants in the Anthropocene

In recent decades, two interrelated major controversies have been unfolding in the area of sex/gender research. (1) Are gender-identity variants to be understood as psychopathology or natural variation? (2) Is gender (and perhaps even sex) better conceptualized as binary or non-binary? The answer depends on the conceptual context and related considerations of utility. In the context of evolutionary biology, marked variants of sex and gender decrease reproductive success and are, thereby, deemed pathologic. In the present era of the anthropocene, however, the material conditions underlying the traditional division of labor between the sexes and the role of reproductive success have dramatically changed. These changes decrease the psychosocial importance of the binary gender distinction, provide more freedom for non-binary gender expression and identity formation, and render the distinction of pathologic and non-pathologic less useful, unless gender dysphoria develops secondary to a psychiatric condition. Although most people state their gender identity in the form of a nominal category, most self-report or interview-based ratings and multi-item scales of gender expression and/or identity show continuous distributions, either unimodal-asymmetric or bimodal, depending on whether they are designed for one or both of the traditional genders. Similarly, the rating scales of androgen-influenced variants of the genitalia-usually designed for one of the traditional sexes-typically represent a unipolar-asymmetric continuum. However, the binary gender system remains the primary framework against which individuals evaluate themselves. For those who develop gender dysphoria, assistance by mental-health service providers continues to be important.

What Is Gender Dysphoria? A Critical Systematic Narrative Review

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association has changed the diagnosis of gender identity disorder to gender dysphoria (GD). In this critical narrative review we ask: What is gender dysphoria? We report on some of the inconsistencies in the articles that foreground distress while obfuscating the fact that not all trans and intersex people suffer stress or impaired functioning, and the inappropriate referencing to intersex people in the diagnostic criterion, claims about the GD diagnosis contributing to the depathologization of and reducing stigma surrounding trans people, the conceptualizations of "gender dysphoric" research subjects, and finally we question the etiological approaches using GD as a conceptual framework. We further suggest that there are a number of methodological issues that need to be resolved to be able to claim that the GD diagnosis can be validated. To shed light on these paradoxes and methodological issues in the DSM-5, we report on the content validity of GD by reviewing research articles postdiagnostic inception. These findings will contribute to the debate about the validity of GD as a diagnosis for the 21st century for those people who need to live a different gender to that assigned at birth.

MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria

Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.

Biological origins of sexual orientation and gender identity: Impact on health

Gynecologic Oncologists are sometimes consulted to care for patients who present with diverse gender identities or sexual orientations. Clinicians can create more helpful relationships with their patients if they understand the etiologies of these diverse expressions of sexual humanity. Multidisciplinary evidence reveals that a sexually dimorphic spectrum of somatic and neurologic anatomy, traits and abilities, including sexual orientation and gender identity, are conferred together during the first half of pregnancy due to genetics, epigenetics and the diversity of timing and function of sex chromosomes, sex-determining protein secretion, gonadal hormone secretion, receptor levels, adrenal function, maternally ingested dietary hormones, fetal health, and many other factors. Multiple layers of evidence confirm that sexual orientation and gender identity are as biological, innate and immutable as the other traits conferred during that critical time in gestation. Negative social responses to diverse orientations or gender identities have caused marginalization of these individuals with resultant alienation from medical care, reduced self-care and reduced access to medical care. The increased risks for many diseases, including gynecologic cancers are reviewed. Gynecologic Oncologists can potentially create more effective healthcare relationships with their patients if they have this information.

Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists

Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.

Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review

CONTEXT

Hormonal interventions are being increasingly used to treat young people with gender dysphoria, but their effects in this population have not been systematically reviewed before.

OBJECTIVE

To review evidence for the physical, psychosocial, and cognitive effects of gonadotropin-releasing hormone analogs (GnRHa), gender-affirming hormones, antiandrogens, and progestins on transgender adolescents.

DATA SOURCES

We searched Medline, Embase, and PubMed databases from January 1, 1946, to June 10, 2017.

STUDY SELECTION

We selected primary studies in which researchers examined the hormonal treatment of transgender adolescents and assessed their psychosocial, cognitive, and/or physical effects.

DATA EXTRACTION

Two authors independently screened studies for inclusion and extracted data from eligible articles using a standardized recording form.

RESULTS

Thirteen studies met our inclusion criteria, in which researchers examined GnRHas (n = 9), estrogen (n = 3), testosterone (n = 5), antiandrogen (cyproterone acetate) (n = 1), and progestin (lynestrenol) (n = 1). Most treatments successfully achieved their intended physical effects, with GnRHas and cyproterone acetate suppressing sex hormones and estrogen or testosterone causing feminization or masculinization of secondary sex characteristics. GnRHa treatment was associated with improvement across multiple measures of psychological functioning but not gender dysphoria itself, whereas the psychosocial effects of gender-affirming hormones in transgender youth have not yet been adequately assessed.

LIMITATIONS

There are few studies in this field and they have all been observational.

CONCLUSIONS

Low-quality evidence suggests that hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact are generally lacking. Future research to address these knowledge gaps and improve understanding of the long-term effects of these treatments is required.

Challenges in assessing personality of individuals with Gender Dysphoria with the SWAP-200

BACKGROUND

Personality assessment can be useful to better understand the complexity of transgender and transsexual people. In particular, the Shedler Westen Assessment Procedure-200 (SWAP-200) is a measure that provides an accurate dimensional evaluation of personality. When assessing gender non-conforming people, however, clinicians can encounter some difficulties in giving appropriate ratings to all the items.

PURPOSE OF THE REVIEW

A brief guide to the use of SWAP-200 with transgender patients is provided, taking into account three areas of psychological functioning: identity, relationships and sexuality. The authors review, one by one, the SWAP-200 items related to these areas, and, relying on their clinical experience and on scientific literature on Gender Dysphoria, they propose recommendations for making personality diagnoses meaningful.

CONCLUSION

This paper facilitates a better clinical understanding of transgender people, and help clinicians to be more knowledgeable in the assessment of this heterogeneous population.

Formations of Femininity: Science and Aesthetics in Facial Feminization Surgery

Facial feminization surgery (FFS) is a set of bone and soft tissue reconstructive surgical procedures intended to feminize the faces of trans- women in order to make their identities as women recognizable to others. In this article, I explore how the identification of facial femininity was negotiated in two FFS surgeons' practices. One committed to the metrics of normal skeletal form and the other to aspirational aesthetics of individual optimization; I argue that surgeons' competing clinical approaches illustrate a constitutive tension in the proliferating therapeutic logics of trans- medicine. The growing popularity of surgical practices like FFS demonstrates a shift in American trans- therapeutics away from a singular focus on the genitalia as the location of bodily sex and toward understandings of sex as a product of social recognition.

Autogynephilia and the Typology of Male-to-Female Transsexualism

Abstract. Sexual scientists have recognized for over a century that biologic males who seek sex reassignment – male-to-female (MtF) transsexuals – are not a homogeneous clinical population but comprise two or more distinct subtypes with different symptoms and developmental trajectories. The most widely used typologies of MtF transsexualism have been based on sexual orientation and have distinguished between persons who are androphilic (exclusively sexually attracted to males) and those who are nonandrophilic (sexually attracted to females, both males and females, or neither gender). In 1989, psychologist Ray Blanchard proposed that most nonandrophilic MtF transsexuals display a paraphilic sexual orientation called autogynephilia, defined as the propensity to be sexually aroused by the thought or image of oneself as a woman. Studies conducted by Blanchard and colleagues provided empirical support for this proposal, leading to the hypothesis that almost all nonandrophilic MtF transsexuals are autogynephilic, whereas almost all androphilic MtF transsexuals are not. Blanchard’s ideas received increased attention in 2003 after they were discussed in a book by psychologist J. Michael Bailey. The concept of autogynephilia subsequently became intensely controversial among researchers, clinicians, and MtF transsexuals themselves, causing widespread repercussions. This article reviews the theory of autogynephilia, the evidence supporting it, the objections raised by its critics, and the implications of the resulting controversy for research and clinical care.

Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking

Since the beginning of contemporary transition-related care at the outset of the 20th century, sexual orientation has ben considered to be closely connected with gender identity and the developmental trajectories of trans people. Specifically, health professionals have regarded the anticipated post-transitional heterosexual behaviour of trans adults as predictive of a good outcome of cross-sex hormones and gender-confirming surgeries. This article reviews the current literature according to the question of whether the sexual orientation of trans people is linked to outcome measures following transition-related interventions. A comprehensive review was undertaken using the Medline database, searching for empirical studies published between 2010 and 2015. Out of a total of 474 studies, only 10 studies reported a follow-up of trans adults and assessed sexual orientation in the study protocol at all. Sexual orientation was predominantly assessed as homosexual versus non-homosexual related to sex assigned at birth. Only one 1 of 10 follow-up studies found a significant association according to the outcome between groups differentiated by sexual orientation. Empirically there is no link between sexual orientation and outcome of transition-related health care for trans adults. In order to provide comprehensive health care, we recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions; however, this knowledge should not drive, but simply inform, such comprehensive care.

Gender incongruence/gender dysphoria and its classification history

In this article we discuss the changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification of gender identity-related conditions over time, and indicate how these changes were associated with the changes in conceptualization. A diagnosis of 'transsexualism' appeared first in DSM-III in 1980. This version also included a childhood diagnosis: gender identity disorder of childhood. As research about gender incongruence/gender dysphoria increased, the terminology, placement and criteria were reviewed in successive versions of the DSM. Changes in various aspects of the diagnosis, however, were not only based on research. Social and political factors contributed to the conceptualization of gender incongruence/gender dysphoria as well.

Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD

The American Psychiatric Association (APA) recently completed a several year process of revising the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). During that time, there were objections raised to retaining DSM's gender identity disorder diagnoses and calls to remove them, just as homosexuality had been removed from DSM-II in 1973. At the conclusion of the DSM-5 revision process, the gender diagnoses were retained, albeit in altered form and bearing the new name of 'gender dysphoria'. The author of this paper was a member of the DSM-5 Workgroup on Sexual and Gender Identity Disorders and presently serves on the WHO Working Group on Sexual Disorders and Sexual Health. Both groups faced similar tasks: reconciling patients' needs for access to care with the stigma of being given a psychiatric diagnosis. The differing nature of the two diagnostic manuals led to two different outcomes. As background, this paper updates the history of homosexuality and the gender diagnoses in the DSM and in the International Statistical Classification of Diseases and Related Health Problems (ICD) as well as what is expected to happen to the homosexuality and gender diagnoses following the current ICD-11 revision process.

Body Satisfaction and Physical Appearance in Gender Dysphoria

Gender dysphoria (GD) is often accompanied by dissatisfaction with physical appearance and body image problems. The aim of this study was to compare body satisfaction with perceived appearance by others in various GD subgroups. Data collection was part of the European Network for the Investigation of Gender Incongruence. Between 2007 and 2012, 660 adults who fulfilled the criteria of the DSM-IV gender identity disorder diagnosis (1.31:1 male-to-female [MtF]:female-to-male [FtM] ratio) were included into the study. Data were collected before the start of clinical gender-confirming interventions. Sexual orientation was measured via a semi-structured interview whereas onset age was based on clinician report. Body satisfaction was assessed using the Body Image Scale. Congruence of appearance with the experienced gender was measured by means of a clinician rating. Overall, FtMs had a more positive body image than MtFs. Besides genital dissatisfaction, problem areas for MtFs included posture, face, and hair, whereas FtMs were mainly dissatisfied with hip and chest regions. Clinicians evaluated the physical appearance to be more congruent with the experienced gender in FtMs than in MtFs. Within the MtF group, those with early onset GD and an androphilic sexual orientation had appearances more in line with their gender identity. In conclusion, body image problems in GD go beyond sex characteristics only. An incongruent physical appearance may result in more difficult psychological adaptation and in more exposure to discrimination and stigmatization.

Gender Dysphoria in Adults

Gender dysphoria (GD), a term that denotes persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Subtypes of GD in adults, defined by sexual orientation and age of onset, have been described; these display different developmental trajectories and prognoses. Prevalence studies conclude that fewer than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females experience GD, but such estimates vary widely. GD in adults is associated with an elevated prevalence of comorbid psychopathology, especially mood disorders, anxiety disorders, and suicidality. Causal mechanisms in GD are incompletely understood, but genetic, neurodevelopmental, and psychosocial factors probably all contribute. Treatment of GD in adults, although largely standardized, is likely to evolve in response to the increasing diversity of persons seeking treatment, demands for greater client autonomy, and improved understanding of the benefits and limitations of current treatment modalities.

Fit to Serve? Exploring Mental and Physical Health and Well-Being Among Transgender Active-Duty Service Members and Veterans in the U.S. Military

Purpose: Although transgender people are currently excluded from enlistment and discharged from service based on medical and psychological fitness policies, the current mental and physical health of transgender active-duty U.S. military personnel and veterans is poorly understood. The purpose of the current study was to investigate the military histories, lifetime mental and physical health diagnoses, and transgender transition-related health of transgender active-duty service members (ADSM) and veterans. Methods: Participants were recruited through private LGBT military and veteran organizational listservs, snowball sampling, and in-person recruitment to complete an anonymous and confidential self-administered online questionnaire. Results: A total of 106 transgender ADSM (n=55) and veterans (n=51) completed the questionnaire. Transgender veterans were significantly older (44 mean years vs. 29.5 mean years, t=-6.23, p<0.001). A greater percentage of veterans than ADSM reported depression (64.6% vs. 30.9%, χ2=11.68, p=0.001) and anxiety (41.3% vs. 18.2%, χ2=6.54, p=0.011). In addition, 15.9% of veterans versus 1.8% of ADSM (χ2=6.53, p=0.011) had been diagnosed with a substance abuse disorder. There were no significant differences in lifetime physical health conditions; however, veterans reported a higher body-mass index than ADSM (28.4 vs. 24.9, t=-3.85, p<0.001). For both groups, mental and physical health problems were positively correlated with age and years of military service (r=0.37-0.84, p<0.01). There were no significant differences between groups in transgender transition-related health. Conclusion: Our data represent the first descriptive statistics of lifetime mental and physical health issues among transgender ADSM and veterans. Data indicate that transgender ADSM report fewer lifetime mental and physical health problems than transgender veterans. Taken together, our findings suggest that more research, specifically among transgender ADSM, is needed to challenge the exclusion of transgender persons from U.S. military service based on the presumption of poor mental or physical health.

Sexual disorders in DSM-5 and ICD-11: a conceptual framework

PURPOSE OF REVIEW

The nature and classification of sexual disorders has been a focus during work on the development of DSM-5 and ICD-11. This article proposes different conceptual approaches to the sexual disorders, including classical, critical and integrative positions. Disorders associated with sexual orientation, gender dysphoria/incongruence and paraphilias/paraphilic disorders are discussed from each of these positions.

RECENT FINDINGS

A range of conventional and nonconventional consensual sexual behaviours are prevalent but not necessarily indicative of a mental disorder; there is little diagnostic validity or clinical utility for including these in the nosology. When such behaviours are clinically excessive and associated with distress or impairment, however, a disorder may be present. Debate surrounds the medicalization of some sexual behaviours that are criminal in nature.

SUMMARY

The classification of sexual behaviour as disordered is necessarily theory-dependent and value-laden. Nevertheless, reasoned debate about the relevant data and values is possible, and will hopefully further improve the diagnostic validity and clinical utility of psychiatric nosology.