Transition memories: experiences of trans adult women with hormone therapy and their beliefs on the usage of hormone blockers to suppress puberty

Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals' Experiences Undergoing Gender-Affirming Hormone Therapy

Gender Affirming Hormone Therapy (GAHT) is a key therapeutic approach which aims to help trans and gender diverse (or simply "trans") individuals' transition from their sex-presumed-at-birth to their experienced gender identity. Previous reviews have focused on synthesizing quantitative experiences; however, a qualitative lens is important to understand the personal journey of GAHT. This review provides a qualitative meta-synthesis of the experiences of trans people around the world who have undergone GAHT to elicit contextualized understanding of the changes experienced. Systematic searches of eight databases identified an initial 2670 papers, refined to a final 28 papers. Overall, findings suggested that the GAHT journey is unique and elicited a myriad of changes which, whilst challenging at times, were life-changing and brought about positive psychological, physical, and social changes. Other themes explored GAHT not being treated as a fix-all for associated mental health issues, the rules that govern appraisal of physical changes, how privilege and social identity evolve, and the power of affirmation. This work offers important recommendations to improve the care offered to trans people undergoing GAHT. Namely, person-centered support is essential, and peer-navigation may be a useful future direction to explore.

Gender Dysphoria: Concepts, Diagnosis and Clinical Management

Gender dysphoria is defined as a condition characterized by mental suffering associated with the incongruence between one's experienced gender and their birth-assigned sex. Gender as a construct and gender dysphoria as a condition in need of multidisciplinary intervention have developed as swiftly as their visibility in society, making it mandatory to promote the literacy and education of all healthcare professionals in this area. This article aims to review information based on scientific evidence on people with gender dysphoria and its clinical approach, while contributing to a safe, inclusive, and non-discriminatory practice of healthcare.

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry

BACKGROUND

In response to the imperative need for standardized support for adolescent Gender Dysphoria (GD), the Italian Academy of Pediatrics, in collaboration with the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine and Italian Society of Child and Adolescent Neuropsychiatry is drafting a position paper. The purpose of this paper is to convey the author's opinion on the topic, offering foundational information on potential aspects of gender-affirming care and emphasizing the care and protection of children and adolescents with GD.

MAIN BODY

Recognizing that adolescents may choose interventions based on their unique needs and goals and understanding that every individual within this group has a distinct trajectory, it is crucial to ensure that each one is welcomed and supported. The approach to managing individuals with GD is a multi-stage process involving a multidisciplinary team throughout all phases. Decisions regarding treatment should be reached collaboratively by healthcare professionals and the family, while considering the unique needs and circumstances of the individual and be guided by scientific evidence rather than biases or ideologies. Politicians and high court judges should address discrimination based on gender identity in legislation and support service development that aligns with the needs of young people. It is essential to establish accredited multidisciplinary centers equipped with the requisite skills and experience to effectively manage adolescents with GD, thereby ensuring the delivery of high-quality care.

CONCLUSION

Maintaining an evidence-based approach is essential to safeguard the well-being of transgender and gender diverse adolescents.

Right Versus Wrong: A Qualitative Appraisal With Respect to Pandemic Trajectories of Transgender Population in Kerala, India

The transgender population generally faces rights violations and discrimination in their day-to-day lives, which was exacerbated during the recent pandemic. This necessitates close scrutiny from an ethics perspective. Following directives from a 2014 Supreme Court judgement, Kerala became the first Indian state to implement a comprehensive policy to enforce the constitutional rights of transgender people. Despite such positive actions, a basic social tendency not to respect gender diversity has led to discrimination and marginalization. This was very evident during the pandemic. In this empirical work, we have documented the lives of the transgender community during the pandemic wherein they share experiences related to livelihood, interaction with the healthcare system, and acceptance in society vis-à-vis the pandemic. Simply providing third-gender status will not help the gender-marginalized community to grow to their fullest potential and have a better lifestyle on par with others in mainstream society.

Equity issues in gender-affirming medical care in Kerala: a reflective commentary

Gender-affirming medical care is the provision of transition-related medical services that support a transgender person's own gender identity. Gender transitioning is a process that requires not only social support but also psychological and medical support, This paper attempts to document the challenges faced by transgender individuals (TG) especially in the context of gender affirming medical care in the Kerala context. The transition process is extremely complex as the preference for such process is varied. Some transgender individuals preferred social transition and/or medical transition to align their gender expression with their gender identity, while others chose to have a gender expression or identity outside the traditional gender binary. In Kerala, despite proactive policy and positive legal support, transgender individuals face many challenges in gender-affirming medical care which include lack of family support and equity-related issues with respect to a number of social support institutions including health services. A few possible interventions are suggested such as changes in medical curriculum, more active State support and sensitization of the society including health workers.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

Exploring Gender Diversity in Transgender and Non-Binary Adults Accessing a Specialized Service in Italy

In Italy, studies investigating gender identity and expression in gender non-conforming adults are lacking, as well as data regarding the non-binary population. The present study aimed at dimensionally exploring how transgender and non-binary Italian adults identify and express their gender. The Gender Diversity Questionnaire (GDQ) was administered to a sample of 112 adult subjects aged 18-60 years accessing a gender-specialized service in Rome. The majority of the participants were aged 18-24 years (53.6%), whereas fewer subjects were aged 25-35 years (32%) and 35 years and older (14.3%). Most participants (83.9%) identified themselves as trans binary, while the remaining (16.1%) identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity over time and across contexts. Younger subjects recognized the use of chosen names, pronouns, and clothes as important for their gender expression, whereas older subjects attributed more importance to physical appearance and emotions. Differences regarding gender-affirmative interventions emerged between non-binary and transbinary participants. Findings evidence that gender non-conforming adults accessing gender-specialized services have unique needs and features, thus it is essential to shed light on this population by providing greater visibility and recognition.

Youth should decide: the principle of subsidiarity in paediatric transgender healthcare

Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients' capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient's identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth's authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves.

Defensive Functioning of Individuals Diagnosed With Gender Dysphoria at the Beginning of Their Hormonal Treatment

Defense mechanisms are relevant indicators of psychological functioning and vulnerability to psychopathology. Their evaluation can unveil individuals' unconscious strategies for mediating reactions to emotional conflict and external stressors. At the beginning of their journey toward gender reassignment, individuals diagnosed with gender dysphoria (GD) may experience conflict and stressful experiences that trigger a wide range of defense mechanisms. Mature defenses may strengthen these individuals as they travel along this important path, while neurotic and immature defenses may exacerbate their body dissatisfaction (BD) and hinder their processing of change. Only a few studies have investigated self-reported defensive functioning in transgender people, finding a higher frequency of maladaptive defense mechanisms relative to controls. The present study was the first to apply an in-depth clinician-rated tool to assess the entire hierarchy of defense mechanisms within a sample of transgender people. Defensive functioning and personality organization were assessed in 36 individuals diagnosed with GD (14 trans women, 22 trans men, mean age 23.47 years), using the Defense Mechanisms Rating Scales (Perry, 1990) and the Shedler-Westen Assessment Procedure-200 (Shedler et al., 2014). Body uneasiness was assessed using the Body Uneasiness Test (BUT; Cuzzolaro et al., 2006). The findings showed that defensive functioning correlated positively with healthy personality functioning and negatively with BD. Compared to cisgender controls, participants with GD who presented greater defensive functioning were found to be more immature and to demonstrate significant differences in many levels of functioning. The clinical implications of the results suggest that psychological interventions aimed at improving defensive functioning in individuals with GD will be important in helping them manage the challenges posed by their gender transition.

Psychological Well-Being of Trans* People in Italy During the COVID-19 Pandemic: Critical Issues and Personal Experiences

Introduction

The COVID-19 pandemic represents risk to physical health and psychological well-being. Specifically, it causes concerns among minoritized communities, such as transgender/non-binary individuals. The study investigates the experience of this group in Italy during the pandemic and identifies risk factors that exerted negative impacts on psychological well-being and physical health.

Methods

The study developed an online questionnaire to investigate psychological status, access to medical health services, and factors such as predictors of risk outcomes among transgender/non-binary people during lockdown restrictions. Responses were collected (n = 256) on April 2020. Descriptive analysis, univariate analysis of variance, and t-test were conducted.

Results

The respondents confirmed several issues, such as worries about the future (58.2%), negative emotions (46.9%), and self-uncertainty (52.7%) during the pandemic. Difficulties in undertaking hormone therapy and access to health facilities were reported. Living with family members represented a significant stressor for psychological well-being, whereas lack of support from LGBT + communities was reported. Subjects undergoing psychological therapy during the pandemic reported increases in depression, anxiety, somatization, and lack of privacy in the household.

Conclusions

The study findings provide a framework for critical aspects experienced by transgender/non-binary individuals during the pandemic. Specifically, the study provides evidence of the vulnerability of this population underlined by multiple difficulties.

Policy Implications

The study findings provide an overview of the experience of transgender and non-binary people during the pandemic, insights regarding risk factors, and aspects that require adequate attention and care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13178-021-00633-3.

Systematic Review: Puberty suppression with GnRH analogues in adolescents with gender incongruity

CONTEXT

Gender incongruence is defined as disharmony between assigned gender and gender identity. Several interventions are liable in this case including genital affirming surgery among other surgical interventions such as harmonization, and also the use of gonadotropin-releasing hormone agonists (GnRHa) for gonadal shielding. This aids in preventing the development of secondary sexual characteristics related to the genetic sex.

OBJECTIVE

Systematically review the treatment of gender incongruity with GnRHa analogues.

DATA SOURCES

The data source of this research is from Pubmed-Medline and Embase.

STUDY SELECTION

Articles published between 2009 and 2019 which studied transgender adolescents treated with GnRHa were carefully selected.

DATA EXTRACTION

Were extracted: design, sample size, study context, targeted subjects of intervention, outcome measures, and results.

RESULTS

Eleven studies were included. The use of GnRHa seems to be well tolerated by the studied population. When started in pubertal transition, it was associated with a more distinct resemblance to body shape than to the affirmed sex. In addition to preventing the irreversible phenotypic changes that occur in cross-hormonal therapy, the use of GnRHa can equally contribute to the mental health of these adolescents.

LIMITATION

There are few consistent studies on the use of GnRHa for gender incongruence.

CONCLUSION

As the population of transgender children and adolescents grows, they acquire knowledge and greater access to the various forms and stages of treatment for sex reassignment. The medical community needs to be adequately prepared to better serve this population and offer the safest resources available.

Gender Diverse Children and Adolescents in Italy: A Qualitative Study on Specialized Centers' Model of Care and Network

In recent years, Italy, similar to many other countries, has witnessed an increase in children and adolescents presenting gender incongruence. This trend has led to the development and implementation of specialized centers providing care and support for these youths and their families. The present study aimed at investigating the functioning of agencies specialized in working with transgender and gender non-conforming youths in the Italian territory. Professionals in these agencies were interviewed about their perspectives on their agency's functioning, networks with other services, and work with trans* youths and their families. A semi-structured interview was developed and administered to professionals in specialized centers and associations dedicated to trans * youths, and deductive thematic analysis was applied to the transcripts. Eight professionals were interviewed: six working in specialized centers and two working in associations. The qualitative analyses of transcripts revealed four main themes, pertaining to service referrals, assessment protocols and intervention models, psychological support for youths and families, and agency shortcomings. The study explored the functioning of Italian agencies specialized in caring for transgender and gender non-conforming youths, from the perspective of professionals working in these agencies. While several positive aspects of the work emerged, the study highlighted a lack of uniformity across the Italian territory and the need for better networks between agencies and other medical professionals.

The Body I Live in. Perceptions and Meanings of Body Dissatisfaction in Young Transgender Adults: A Qualitative Study

Body dissatisfaction in individuals with Gender Incongruence (GI) represents a primary source of suffering. Several studies have highlighted how this suffering has psychological, physical, and biological implications. This work aims to explore experiences related to body dissatisfaction and investigate the issues associated with living in a body perceived as incongruent for individuals with GI. Thirty-six individuals, aged between 18 and 30 years old and at stage T0 of hormone treatment, participated in the study. Body dissatisfaction and experiences related to it were investigated using the Clinical Diagnostic Interview. The Consensual Qualitative Research methodology was applied to the transcripts of the interviews. Several themes emerged: experiences with GI development, experiences with puberty and bodily changes, perception of one’s body, psychological problems and complex behavioral patterns related to body dissatisfaction. Results pointed out the complexity implied in the relationship with one’s body for individuals with GI, highlighting specific aspects of body dissatisfaction among these individuals (e.g., eating disorders, sexual difficulties, social withdrawal). This study underlines the need for a deeper understanding of some aspects of GI to better define guidelines for a correct assessment of it. In this way it will be easier to avoid negative outcomes for the psychological and general health of transgender people.

Transition Trajectories: Contexts, Difficulties and Consequences Reported by Young Transgender and Non-Binary Spaniards

The transition process can have a significant impact on young transgender and non-binary individuals (TNBI), especially regarding their mental health. As such, this study aimed to explore the encountered difficulties and expectations of 225 young adults, between 14 and 25 years old, who identify themselves as TNBI. Four different aspects were analyzed: difficulties related to the transition process; main current difficulties; if the current difficulties are due to the participants’ sexual orientation or gender identity; and if participants feel the need of changing something in their lives. Several obstacles either before, during or after the transition process were identified; and these obstacles have serious consequences in TBNI’s mental health. Questions regarding legislation, discrimination, transphobia, lack of social support, the pathologization of transgenderism, low self-esteem, anxiety symptomatology, among others, were pointed out by the participants. The narratives collected and analyzed in the present study appear as important inputs to the literature, which can be translated into the basis of further investigations and the improvement of professional practices in the health field.

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.

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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.