Trans is not a disorder – but should still receive funding

Integrity and rights to gender-affirming healthcare

Gender-affirming healthcare (GAH) interventions are medical or surgical interventions that aim to allow trans and non-binary people to better affirm their gender identity. It has been argued that rights to GAH must be grounded in either a right to be cured of or mitigate an illness-gender dysphoria-or in harm prevention, given the high rates of depression and suicide among trans and non-binary people. However, these grounds of a right to GAH conflict with the prevalent view among theorists, institutions and activists that trans and non-binary people do not have a mental illness and that one can be trans and entitled to GAH without being depressed or suicidal. This paper challenges the orthodoxy that a right to GAH must be grounded in either of these ways and instead argues for a right to GAH grounded in a right to live and act with integrity. The standard view, which this paper explains, is that our rights to live and act with integrity ground a right to religious accommodation in many cases such as a right to not be denied social security due to one's refusal to work a job on a holy day. This paper argues that if our rights to live and act with integrity can ground prima facie rights to religious accommodation, our rights to live and act with integrity ground prima facie rights to GAH.

Identifying coping strategies used by patients at a transgender health clinic through analysis of free-text autobiographical narratives

BACKGROUND

This paper presents an analysis of 32 narratives written by patients waiting for assessment at a transgender health clinic (THC) in England. Narratives are autobiographical free texts, designed to allow patients to describe in their own words their experiences of their gender identity and/or transition prior to a clinic appointment, as part of the assessment process.

OBJECTIVE

Narratives were analysed to identify actions prospective patients had taken to manage their (usually lengthy) waiting times, so that these 'coping strategies' could be shared with future patients.

DESIGN

Corpus linguistic methodology was utilized to identify common patterns across the whole corpus of text-based data, augmented with more detailed sociolinguistic analysis of individual narratives.

RESULTS

There are broad commonalities in the way the transition experience is described across the corpus in terms of presentation of key experiences and feelings. There are specific descriptions of a number of recurring coping strategies, both positive and negative.

CONCLUSION

The empowerment value of writing these narratives may be limited; the existence of recurring key features suggests that patients may feel they have to present their experiences in certain ways to be accepted for treatment. However, dissemination of some positive coping strategies may help future clients of THCs to better cope with waiting times, as well as assisting practitioners in THCs in supporting their patients during this wait.

PATIENT/PUBLIC CONTRIBUTION

The clinic's Service Users' Research Advisory Group contributed to formulating the objective and design of the study. Results were presented at the clinic's annual PPI conference.

Gender Dysphoria, Eating Disorders and Body Image: An Overview

Background::

Gender dysphoria is a clinical condition in which a state of inner suffering, stress and anxiety is detected when biological sex and a person's gender identity do not coincide. People who identify themselves as transgender people are more vulnerable and may have higher rates of dissatisfaction with their bodies which are often associated with a disorderly diet in an attempt to change the bodily characteristics of the genus of birth and, conversely, to accentuate the characteristics of the desired sexual identity.

Aim::

The purpose of this work is to examine the association between dissatisfaction with one's own body and eating and weight disorders in people with gender dysphoria.

Results::

Gender dysphoria and eating disorders are characterized by a serious discomfort to the body and the body suffers in both conditions. The results of our study suggest that rates of pathological eating behaviors and symptoms related to a disordered diet are high in patients with gender dysphoria and that standard screening for these symptoms must be considered in both populations at the time of evaluation and during the course of the treatment.

Conclusions::

In light of this evidence, clinicians should always investigate issues related to sexuality and gender identity in patients with eating disorders, to develop more effective prevention measures and better strategies for therapeutic intervention..

Accuracy of psychometric tools in the assessment of personality in adolescents and adults requesting gender-affirming treatments: A systematic review

BACKGROUND

The assessment and screening for personality disorders in individuals requesting gender affirming treatments may be an important aspect of predicting medical and surgical outcomes for this population, but there is no consensus on how best to do so.

AIMS

To review the diagnostic accuracy of psychometric tools used for the assessment of personality disorders in those requesting gender affirming treatments.

METHOD

A systematic review: Prospero CRD42017078783 [1].

RESULTS

Many studies have focussed on the assessment of personality disorders in this population, but since 1979, only two have used an index and reference test.

CONCLUSION

There are no agreed reference standards for this population and psychometric tools continue to be scored on reference data from the cisgender (not transgender) population. We need robust evidence on this issue, as individuals may be denied access to gender affirming treatments based on psychometric tools without established reliability in this population.

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

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

Transitioning Bodies. The Case of Self-Prescribing Sexual Hormones in Gender Affirmation in Individuals Attending Psychiatric Services

Self-prescribing of sexual hormones for gender affirmation is a potentially widespread and poorly studied phenomenon that many clinicians are unaware of. The uncontrolled use of hormones poses significant health hazards, which have not been previously reported in the literature. We have collected seven clinical cases in general adult psychiatry settings (both inpatient and outpatients), describing transgender and gender non-conforming individuals' (TGNC) self-prescribing and self-administering hormones bought from the Internet without any medical consultation. Among these cases, two were taking androgens, and the rest were taking oestrogens. The main reason for self-administration of hormones seems to be the lack of access to specialised care due to discrimination and long waiting lists. We advocate for clinicians to be aware of the phenomenon and proactively help TGNC individuals by enquiring about self-prescribing of hormones, providing information and referring to the most appropriate treatment centre as well as encourage a public debate on the discrimination and the stigma that TGNC population suffer from. Overall, there is an urgent need for the implementation of different and innovative health care services for TGNC individuals as well as more targeted prevention strategies on such underreported and highly risky behaviours. Furthermore, it is necessary for every clinician involved in the care for TGNC people to be aware of their special needs and be able to be an allied and an advocate to help in reducing stigma and discrimination that affect the access to care for this often underserved population.

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.

Mental health and gender dysphoria: A review of the literature

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.