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Cortez S, Moog D, Baranski E, Williams K, Wang J, Nicol G, Baranski T, Herrick CJ. Assessment of sociodemographic and psychiatric characteristics of transgender adults seen at a Midwest tertiary medical center. Front Endocrinol (Lausanne) 2024; 15:1445679. [PMID: 39296718 PMCID: PMC11408213 DOI: 10.3389/fendo.2024.1445679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 08/13/2024] [Indexed: 09/21/2024] Open
Abstract
Background The National Academy of Medicine has formally identified transgender adults as an understudied population in critical need of health research. While national surveys, like the US Transgender survey, have characterized higher rates of depression, anxiety, suicidality and socioeconomic need in the transgender community, studies have not examined the impact of sociodemographic and clinical characteristics on mental health related outcomes. Objective To describe the sociodemographic and mental health characteristics of transgender adults seen at a large Midwest transgender clinic and to determine factors associated with self-reported mental health conditions. Methods Descriptive, retrospective, cross-sectional study of new transgender patients 18 years and older seen at a large Midwest transgender clinic between December 2019 and June 2022. Results A total of 482 charts were reviewed. During their initial evaluation, 11.6% (56/482) reported having a history of suicide attempt and 81.3% (392/482) reported a mental health diagnosis with the most common being depression, anxiety, attention deficit disorder, and post-traumatic stress disorder. Multivariable logistic regression results show no single factor was significantly associated with mental health diagnosis after adjusting for the effect of age and race. Patients who were new to gender affirming hormone therapy (54%, 254/468) are 2.0 (95% CI 1.4-2.9) times more likely to report having a mental health care provider than patients who were seen for continuation of therapy (46%, 214/468). Ten records with race not disclosed, 3 records with gender identity "other" and 2 records with gender identity not disclosed were excluded from analysis. Conclusion This study reinforces the finding that transgender adults have an increased lifetime prevalence of mental health conditions. The higher prevalence of mental health conditions in our clinic was not associated with sociodemographic factors included in the study. Furthermore, transgender patients are less likely to have seen mental healthcare providers after initiation of gender affirming hormone therapy.
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Affiliation(s)
- Samuel Cortez
- Department of Pediatrics, Division of Endocrinology and Diabetes, Washington University School of Medicine, Saint Louis, MO, United States
| | - Dominic Moog
- Washington University School of Medicine, Saint Louis, MO, United States
| | - Elizabeth Baranski
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Research, Washington University School of Medicine, Saint Louis, MO, United States
| | - Kelley Williams
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Research, Washington University School of Medicine, Saint Louis, MO, United States
| | - Jinli Wang
- Center for Biostatistics and Data Science, Washington University School of Medicine, Saint Louis, MO, United States
| | - Ginger Nicol
- Department of Psychiatry, Washington University School of Medicine, Saint Louis, MO, United States
| | - Thomas Baranski
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Research, Washington University School of Medicine, Saint Louis, MO, United States
| | - Cynthia J Herrick
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Research, Washington University School of Medicine, Saint Louis, MO, United States
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, Saint. Louis, MO, United States
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2
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Kiely E, Millet N, Baron A, Kreukels BPC, Doyle DM. Unequal geographies of gender-affirming care: A comparative typology of trans-specific healthcare systems across Europe. Soc Sci Med 2024; 356:117145. [PMID: 39067377 DOI: 10.1016/j.socscimed.2024.117145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 06/09/2024] [Accepted: 06/15/2024] [Indexed: 07/30/2024]
Abstract
RATIONALE Gender-affirming healthcare can carry significant benefits for trans people. However, there are substantial geographical inequalities in the provision of and access to trans-specific healthcare across Europe. Comparative healthcare systems research has typically focused on universal services, neglecting provision which serves specific groups within populations (e.g., trans people). OBJECTIVE This study aimed to develop a comparative typology of trans-specific healthcare systems across 28 European countries (the EU 27 plus the UK), and to examine country-level correlates which may influence or be influenced by these systems. METHODS Using hierarchical and k-means cluster analysis, countries were classified into four types based on measures of trans-specific healthcare provision, regulation and access. Possible country-level correlates (including socio-political climate, medical outcomes, and the general healthcare system) were investigated. RESULTS AND DISCUSSION The cluster analysis identified four clusters of trans-specific healthcare systems in Europe, characterized as: 1) Centralized conservative (highly centralized, extensive range of treatments, few trans-specific government policies); 2) Centralized reformist (highly centralized, extensive range of treatments, multiple trans-specific government policies); 3) Decentralized marketized (highly decentralized, moderate range of treatments, few trans-specific government policies); 4) Underdeveloped (highly decentralized, limited range of treatments, few or no trans-specific government policies). We found statistically significant differences between the clusters in rates of: public support for trans people; gender identity concealment; treatment access; overall health expenditure; gender inequality. CONCLUSIONS The study develops a novel typology of trans-specific healthcare systems in Europe. It also identifies a range of potential drivers and outcomes of geographical divergences and inequalities in trans-specific healthcare provision. Building on this typology, future comparative research should aim to link the structure of healthcare systems to outcomes for trans people. Comparative healthcare systems research must account for the distinctive forms taken by services and systems that provide healthcare to specific groups within populations.
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Affiliation(s)
- Ed Kiely
- Department of Medical Psychology, Amsterdam UMC, the Netherlands; Department of Geography, University of Cambridge, United Kingdom
| | - Nessa Millet
- Department of Medical Psychology, Amsterdam UMC, the Netherlands
| | - Asher Baron
- Department of Sociology, Columbia University, New York, NY, 10027, USA
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Doyle DM, Link BG. On social health: history, conceptualization, and population patterning. Health Psychol Rev 2024; 18:619-648. [PMID: 38349646 PMCID: PMC11332409 DOI: 10.1080/17437199.2024.2314506] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/31/2024] [Indexed: 08/20/2024]
Abstract
We propose a psychologically-informed concept of social health to join physical and mental components in a more comprehensive assessment of human health. Although there is an extensive literature on the importance of social relationships to health, a theoretical framework is needed to coalesce this work into a codified conceptualisation of social health, defined here as adequate quantity and quality of relationships in a particular context to meet an individual's need for meaningful human connection. Informing this novel conceptualisation, we outline eight key propositions to guide future research and theory on social health, including five propositions focused on the conceptualisation of social health and three focused on its population patterning. The former five propositions include that social health is an outcome in its own right, that health interventions can have divergent effects on social versus physical and mental aspects of health, that social health has independent effects on quality of life, that it is a dynamic and contextual construct, and that it is embedded and encoded in the human body (and mind). The utility of the social health concept is further revealed in its significance for understanding and addressing population health concerns, such as health inequalities experienced by marginalised groups.
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Affiliation(s)
- David Matthew Doyle
- Department of Medical Psychology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Bruce G. Link
- School of Public Policy and Department of Sociology, University of California, Riverside, CA, US
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4
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Sagar RC, Millson-Brown V. Gender-affirming hormone treatment modalities for transfemale & non-binary transfeminine individuals: A UK perspective. Best Pract Res Clin Endocrinol Metab 2024; 38:101921. [PMID: 39232976 DOI: 10.1016/j.beem.2024.101921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Abstract
Gender incongruence and the number of people seeking gender affirming hormone treatment has dramatically risen in the last two decades. In the UK, transgender women and non-binary transfeminine individuals are typically treated with simultaneous suppression of endogenous testosterone production through anti-androgens and exogenous oestradiol replacement. Oestrogen replacement comes in different forms and is primarily given as transdermal (gel or patch) or oral preparations in the UK. Decisions around preparation choice are based on a combination of individual preference and/or mitigating the chance of complications based on individual risk profiles. Time frames to achieve female physical changes are largely predictable and managing expectations of individuals prior to commencing treatment is highly important. Common complications include venous thromboembolism, liver dysfunction and effects on fertility, thus individuals should be thoroughly counselled prior to commencing treatment. This article provides an overview of the management and considerations of gender-affirming hormone treatment in transgender women and non-binary transfeminine individuals.
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Affiliation(s)
- Rebecca C Sagar
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, LS2 9JT, United Kingdom
| | - Victoria Millson-Brown
- Gender Identity Service, The Newsam Centre, Seacroft Hospital, Leeds LS14 6UH, United Kingdom.
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5
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Gieles NC, Kroon MAGM, Both S, Heijboer AC, Kreukels BPC, den Heijer M. Addition of testosterone to endocrine care for transgender women: a dose-finding and feasibility trial. Eur J Endocrinol 2024; 191:279-287. [PMID: 39163572 DOI: 10.1093/ejendo/lvae103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/01/2024] [Accepted: 08/16/2024] [Indexed: 08/22/2024]
Abstract
OBJECTIVE Transgender women who underwent gonadectomy have lower serum testosterone concentrations than cisgender women. There is uncertainty regarding the dosing and side effects of supplementation of testosterone in transgender women. This study aimed to assess the feasibility of dosing testosterone to the cisgender female physiological range in transgender women. In addition, we explored changes in cardiovascular parameters, virilizing side effects, and clinical symptoms. DESIGN This is an open-label, single-arm feasibility study. Participants initially went through a dose-titration phase with 2-week intervals of 0.07-0.09-0.13 mL (277-318-403 μg bioavailable testosterone) testosterone 2% gel to establish a dose leading to serum testosterone concentrations between 1.5 and 2.5 nmol/L. This dose was then continued for 8 weeks. METHODS Participants applied daily transdermal testosterone 2% gel (Tostran®) at the prescribed dosage. Testosterone was measured every 2-4 weeks. Laboratory analyses, side effects, and clinical symptoms were evaluated. RESULTS In total, 12 participants were included. Most participants required a dose of 0.07 mL (277 μg bioavailable testosterone) or 0.09 mL (318 μg bioavailable testosterone) to reach serum testosterone concentrations of 1.5-2.5 nmol/L. Continuing this dose, testosterone concentrations remained stable throughout the study. Changes in clinical outcomes were in the desired direction, and side effects were mild. CONCLUSIONS The use of testosterone supplementation in transgender women seems feasible and safe in the short term. Although dosing requires personalized titration, stable testosterone levels can be established. A blinded, placebo-controlled, randomized clinical trial is needed to study the clinical benefit.
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Affiliation(s)
- Noor C Gieles
- Department of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Public Health (APH) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Maurice A G M Kroon
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology & Metabolism (AGEM) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Stephanie Both
- Department of Sexology and Psychosomatic Gynecology and Obstetrics, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Amsterdam Gastroenterology, Endocrinology & Metabolism (AGEM) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam UMC location Vrije Universiteit Amsterdam, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, Amsterdam UMC location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Amsterdam Public Health (APH) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development (AR&D) Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, Center of Expertise on Gender Dysphoria, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Erasmus J. Addressing the misconceptions in gender-affirming care: Response to Amos (2024). Australas Psychiatry 2024:10398562241274341. [PMID: 39191528 DOI: 10.1177/10398562241274341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
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Periša A, Arbanas G. Differences in Subjective Transition Outcomes Between Transgender and Gender-Diverse Individuals Who Completed Mandatory Psychiatric Assessment and Those Who Received Gender-Affirmative Medical Treatment in Croatia: A Cross-Sectional Online Survey. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:2897-2904. [PMID: 39009740 DOI: 10.1007/s10508-024-02932-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 06/05/2024] [Accepted: 06/07/2024] [Indexed: 07/17/2024]
Abstract
The aim of this study was to evaluate different aspects of transition outcomes in groups of transgender and gender diverse (TGD) people based on their transition status. We divided the 70 TGD participants (19 individuals assigned male at birth and 51 assigned female at birth) into two groups: those who had completed their psychiatric and psychological evaluation (PPE), which is mandatory in Croatia, and those who had undergone gender-affirming medical treatment (GAMT) (both gender-affirming hormone treatment and gender-affirming surgery). The online survey included sociodemographic questions and a custom-designed nine-item scale. The items were specifically designed based on the DSM-5-TR criteria for gender dysphoria to assess subjectively perceived transition outcomes. We conducted a factor analysis of the scale followed by structural equation modeling for confirmation. Chi-squared and Mann-Whitney U tests were used to compare group differences. The following three-factor structure was confirmed: better functioning, reduced body dysphoria, and satisfaction with decision. A positive influence of better functioning on satisfaction with the decision was found. In addition, our results showed that TGD individuals who had undergone GAMT scored higher on better functioning than those who had just completed PPE. Both groups consistently scored high on satisfaction with the decision, with no statistically significant differences between them. Our findings suggest that TGD individuals view gender-affirming medical care as beneficial to their overall functioning.
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Affiliation(s)
- Ante Periša
- University Psychiatric Hospital Vrapče, Bolnička Cesta 32, 10090, Zagreb, Croatia.
| | - Goran Arbanas
- Department of Forensic Psychiatry, University Psychiatric Hospital Vrapče, Zagreb, Croatia
- Faculty of Medicine, University of Rijeka, Rijeka, Croatia
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8
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Mazur M, Larionow P. The Effects of Gender-Affirming Hormone Therapy on Quality of Life: The Importance of Research on Youth. Healthcare (Basel) 2024; 12:1336. [PMID: 38998870 PMCID: PMC11241674 DOI: 10.3390/healthcare12131336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/25/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024] Open
Abstract
Gender-affirming hormone therapy (GAHT) plays a significant role in the medical care of transgender individuals, helping to align their physical characteristics with their gender identity. While numerous studies have investigated the impact of GAHT on adults, research focusing on its effects on the quality of life (QoL) of transgender youth is limited. In this opinion paper, we aim to address selected challenges associated with gender-affirming medical care, such as (1) the necessity for evidence-based youth gender-affirming medical care, (2) the urge to explore different approaches to gender-affirming medical care diversely in transgender youth research, and (3) understanding the challenges of the detransition process (which refers to stopping or reversing gender-affirming medical or surgical treatments), as well as suggest possible solutions for meaningful progress. Notably, the available evidence underlines a positive impact of GAHT on various aspects of QoL of transgender youth, such as mental health and social functioning, by alleviating gender dysphoria, improving body satisfaction, and facilitating appearance congruence (the degree to which an individual's physical appearance represents their gender identity). However, challenges related to methodological limitations, as well as ethical considerations, and several sociocultural factors highlight the need for further research to better understand the long-term effects of GAHT on the QoL of transgender youth. Ethical considerations, such as ensuring informed consent and weighing potential benefits against risks, are pivotal in guiding healthcare decisions. Additionally, navigating these ethical responsibilities amid sociocultural contexts is crucial for providing inclusive and respectful care to transgender youth. Addressing these research gaps is, therefore, crucial to developing successful healthcare programmes, raising awareness, and promoting the holistic well-being of transgender youth through comprehensive and affirming care.
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Affiliation(s)
| | - Paweł Larionow
- Faculty of Psychology, Kazimierz Wielki University, 85-064 Bydgoszcz, Poland
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Heinen CS. Medical Management of Gender Diversity. Oral Maxillofac Surg Clin North Am 2024; 36:151-159. [PMID: 38281895 DOI: 10.1016/j.coms.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
This article provides context on the experiences and medical care of individuals who experience gender dysphoria for the benefit of oral and maxillofacial surgeons. The mechanism of action, effects, and side effects of medical therapies used for gender-affirming care are reviewed. Specific guidance for anesthetic care is given. Trauma-informed tools for care of transgender and gender-diverse patients are offered.
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Affiliation(s)
- Corinne S Heinen
- Family Medicine and Internal Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA; Harborview Medical Center, 325 9th Avenue, Box 359930, Seattle, WA 98104, USA.
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Skinner SR, McLamore Q, Donaghy O, Stathis S, Moore JK, Nguyen T, Rayner C, Tait R, Anderson J, Pang KC. Recognizing and responding to misleading trans health research. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2024; 25:1-9. [PMID: 38328590 PMCID: PMC10846477 DOI: 10.1080/26895269.2024.2289318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- S. Rachel Skinner
- Department of Adolescent Medicine, Children’s Hospital Westmead, Sydney Children’s Hospitals Network, Westmead, Australia
- Children’s Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, Australia
| | | | - Olivia Donaghy
- Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
- School of Psychology, University of Queensland, Brisbane, Australia
| | - Stephen Stathis
- Child and Youth Mental Health Service, Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Julia K. Moore
- Child and Adolescent Health Service Gender Diversity Service, Perth Children’s Hospital, Perth, Australia
- School of Psychiatry and School of Paediatrics and Child Health, The University of Western Australia, Nedlands, Australia
| | - Tram Nguyen
- Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia
| | - Cate Rayner
- Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia
| | - Robert Tait
- Maple Leaf House, John Hunter Children’s Hospital, Newcastle, Australia
| | | | - Ken C. Pang
- Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia
- Murdoch Children’s Research Institute, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
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Pullen Sansfaçon A, Gravel É, Gelly M, Planchat T, Paradis A, Medico D. A retrospective analysis of the gender trajectories of youth who have discontinued a transition. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2024; 25:74-89. [PMID: 38328586 PMCID: PMC10846427 DOI: 10.1080/26895269.2023.2279272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Background: Detransition is frequently covered in the media as a return to a cis identity after transition. Detransition is often studied in isolation and fails to examine it in context of various stages leading to detransition. Aim: To present the perspectives and reflections of youth who have detransitioned on their journey from early transition to discontinuation, focusing on three key dimensions: gender modalities, sexual modalities, and dysphoria experiences, and their evolution during this journey. Method: We drew from 20 in-depth interviews with young people aged 16 to 25 who have discontinued a transition and examined various stages of the gender journey from early transition to detransition. Youth narratives were analyzed thematically and longitudinally. Results: We developed three main themes related to the gender journey: nonlinear gender modalities, navigating sexual modalities along with gender modalities, and coping with dysphoria and body discomfort. We found a great diversity of experiences with regard to these within each participant and across the sample. Discussion: Transition and detransition trajectories are nonlinear and heterogeneous, without any identified commonalities that enable the prediction of outcomes after transitions. However, transnormativity may influence how people who detransition are expected to conform to a certain narrative despite the diversity of experiences present in this community.
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Affiliation(s)
- Annie Pullen Sansfaçon
- School of Social Work, University of Montreal, Montreal, Quebec, Canada
- Canada Research Chair on Partnership Research and Empowerment of Vulnerable Youth, University of Montreal, Montreal, Quebec, Canada
| | - Élio Gravel
- Canada Research Chair on Partnership Research and Empowerment of Vulnerable Youth, University of Montreal, Montreal, Quebec, Canada
| | - Morgane Gelly
- Canada Research Chair on Partnership Research and Empowerment of Vulnerable Youth, University of Montreal, Montreal, Quebec, Canada
| | - Tommly Planchat
- Canada Research Chair on Partnership Research and Empowerment of Vulnerable Youth, University of Montreal, Montreal, Quebec, Canada
| | - August Paradis
- Canada Research Chair on Partnership Research and Empowerment of Vulnerable Youth, University of Montreal, Montreal, Quebec, Canada
| | - Denise Medico
- Departement of Sexology, Université du Québec à Montréal, Montreal, Quebec, Canada
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