Transgender and anxiety: A comparative study between transgender people and the general population

Romantic relationships buffer minority stress in transgender and non-binary adults: Effects on depressive symptoms and suicidality

BACKGROUND

Transgender and non-binary (TNB) individuals are at greater risk of mental health concerns relative to their cisgender peers due to experiences of minority stress. Thus, it is critically important to identify factors that may be protective and buffer the effects of minority stress. This study examined whether romantic relationship involvement and quality buffered effects of TNB minority stress on depressive symptoms and suicidal ideation.

METHODS

A large international sample (n = 1156) of TNB adults (n = 654 partnered; n = 502 single) reported on minority stress experiences, relationship status and quality, and mental health outcomes (i.e., depressive symptoms and suicidal ideation).

RESULTS

The effects of victimization and rejection on depressive symptoms and suicidal ideation were attenuated among partnered individuals. However, once relationship quality was considered, the buffering effects of relationship involvement applied only to those in more satisfying relationships; the stress-buffering effects were not observed among those in distressed relationships. Of particular importance, general interpersonal satisfaction did not act as a minority stress buffer, suggesting there may be unique stress-buffering effects of being in a satisfying romantic relationship on depressive symptoms and suicidal ideation.

LIMITATIONS

The cross-sectional nature of the current study precludes definitive conclusions regarding causation.

CONCLUSIONS

These findings suggest that romantic involvement may serve a stress-buffering role for TNB adults, but only when these relationships are satisfying. Our results have important theoretical and clinical implications, and further research is needed to investigate the utility of relationship interventions to buffer the effects of TNB minority stress on depressive symptoms and suicidality.

Sociodemographic representation in randomized controlled trials for anxiety-related disorders in the U.S.: A systematic review (1993-2023)

Cognitive behavioral therapies have been identified as evidence-based treatments for anxiety-related disorders. However, data supporting the effectiveness of these treatments have been largely collected from participants with majoritized identities, potentially limiting the extent to which they can be considered "evidence-based" for clients from minoritized groups. The current review examined sociodemographic representation and quality of sociodemographic reporting in randomized controlled trials for anxiety-related disorders in the U.S. between 1993 and 2023. We conducted a systematic literature review of U.S.-based randomized controlled trials of cognitive behavioral therapies for anxiety-related disorders, extracted data on sociodemographic variables, and rated quality of reporting. Data from 55 eligible studies (N = 4492) indicated that white and female identities were overrepresented relative to the U.S. population, with variables like disability status, sexual orientation, and religious identification consistently ignored. In addition, quality of reporting was generally poor (mean = 3.6 out of 10), with many studies failing to account for demographic variables in their analyses or description of study limitations. Publication year, sample size, and NIH funding status did not significantly predict gender representation (% women), ethnoracial representation (% white), or quality of reporting. These findings underscore the importance of critically evaluating to whom "evidence-based" treatments apply and increasing diversity of clinical samples, to ensure that evidence-based treatments are inclusive. Recommendations for future research, clinical implications, and limitations are discussed.

Perioperative Patient-Initiated Communication in Gender-Affirming Mastectomy

Background: Gender-affirming mastectomy (GAM) improves the psychosocial functioning and quality of life of transgender and non-binary (TGNB) individuals. However, the perioperative period is often marked by emotional stress, concerns about surgical outcomes, and physical discomfort. While inpatient procedures provide multiple opportunities to engage with and educate patients, outpatient surgeries, such as GAM, pose a unique challenge as patients are followed for <24 h postoperatively. Given the heightened emotional and psychological distress related to gender dysphoria TGNB individuals often experience, addressing these gaps can significantly improve outcomes. This study aims to characterize patient and surgical characteristics associated with patient-initiated communication (PIC) frequency in this population. Methods: A single-center retrospective review of TGNB patients undergoing GAM from February 2018 to November 2022 was conducted. Demographics, surgical characteristics, and frequency of and reasons for perioperative PIC (30 days before and after surgery) were recorded. The primary outcome was the incidence of perioperative PIC. The secondary outcomes included (1) the rationale for PIC and (2) patient and surgical characteristics associated with PIC. Results: A total of 352 patients were included. Of these, 285 (74.6%) initiated communication in the perioperative period, totaling 659 PICs. The median age was 25.0 (interquartile range [IQR]: 9.0) years. The median body mass index (BMI) was 28.5 (IQR: 8.5) kg/m2. The mean number of PICs was 0.7 ± 1.3 preoperatively and 1.3 ± 1.7 postoperatively (p < 0.001). The most frequent preoperative PIC subjects were administrative issues (AI; n = 66, 30.7%), preoperative requirements (n = 43, 20.0%), and cost and insurance (n = 33, 15.0%). The most frequent postoperative PIC subjects were wound care (n = 77, 17.3%), AI (n = 70, 15.0%), activity restrictions (n = 60, 13.5%), drainage (n = 56, 12.6%), and swelling (n = 37, 8.3%). Collectively, older patients (β = 0.234, p = 0.001), those with a history of major depressive disorder or generalized anxiety disorder (2.4 ± 3.0 vs. 1.7 ± 1.9; p = 0.019), and those without postoperative drains (n = 16/17, 94.1% vs. n = 236/334, 70.7%; p = 0.025) engaged in higher levels of PIC. There were no significant associations between other patient characteristics, perioperative details, or complications and PIC frequency. Conclusions: Perioperative PIC is prevalent among the majority of GAM patients at our institution, with age, psychiatric diagnosis, and postoperative drain use identified as significant predictors. To mitigate PIC frequency, it is crucial to ensure adequate support staffing and provide comprehensive postoperative instructions, particularly concerning activity restrictions and drainage management. These interventions may reduce PICs in high-volume centers. Further research should investigate targeted interventions to further support TGNB patients during the perioperative period.

Physical Activity, Anxiety, Depression, and Body Image in Trans Individuals: An Exploratory Study

Physical activity (PA), mental health, and body image are some important health topics in the transgender population that have been recently discussed and appear to play a crucial role in the quality of life of the trans population. This study aims to elucidate the complex interplay of these variables and their implications for the well-being of trans individuals.

METHODS

In a cross-sectional study, 75 Portuguese transgender individuals (M = 23.68; SD ± 6.59) were recruited to participate in this study. The participants completed three questionnaires related to the assessment of physical activity (IPAQ), depressive and anxious symptomatology (HADS), and satisfaction with body image (BISQp).

RESULTS

Trans individuals showed a total energy expenditure of 3316.40 metabolic equivalent tasks (METS), had a moderate level of anxiety symptomatology, and low levels of satisfaction with body image. Satisfaction with body image was negatively associated with anxiety (r = -0.441, p < 0.01) and depression symptomatology (r = -0.600, p < 0.01).

CONCLUSIONS

The implementation of inclusive programs that promote body acceptance and coping strategies, particularly within the context of physical exercise, may help alleviate distress related to body image dissatisfaction while also addressing underlying anxiety and depression symptoms.

The influence of the severity of gender dysphoria on anxiety, depression, suicidal ideation, and non-suicidal self-injury in Chinese transgender, nonbinary, and gender-diverse youth

Background: Gender dysphoria (GD) is frequently reported among transgender, nonbinary, and gender-diverse (TNG) populations, and is closely related to anxiety, depression, suicidal ideation, and non-suicidal self-injury (NSSI). This study aimed to understand how GD influences the four mental health disparities among TNG youth, and to compare these outcomes depending on the severity of GD. Methods: 96,218 College students participated in the survey, of which the analysis was run on an extracted sub-set data of 2,315 (2.40%) TNG youth, with a mean age of 19.46 (SD = 1.52). Self-reported inventories measured sociodemographic factors, the severity of GD (Utrecht Gender Dysphoria Scale-Gender Spectrum), anxiety (seven-item Generalized Anxiety Disorder Questionnaire), depression (nine-item Patient Health Questionnaire), suicidal ideation (Suicidal Behaviors Questionnaire-Revised), and NSSI (Clinician-Rated Severity of Non-Suicidal Self-Injury Scale). Binary logistic regression assessed the association between significant GD and the four psychiatric disorders. Adjusted multiple logistic regression, and directed acyclic graph (DAG) analyses were conducted to explore the activating relationship among GD, sociodemographic factors, and psychiatric disorders. Results: 1,582 (68.30%) TNG youth who experienced significant levels of GD (total scores cutoff >= 46) were entered into the analyses. Binary logistic regression displayed significantly positive associations between significant GD and anxiety, depression, suicidal ideation, and NSSI. Multiple regression models showed risk factors included poor relationship with one's father/mother, tobacco smoking, alcohol consumption, and having a lower subjective social status. While family harmony, a higher father's educational level, and partaking in exercise were protective factors that exerted distinct impacts on these four psychiatric disorders. DAG findings showed a poor relationship with one's father with significant GD via other socio-demographic characteristics, activated psychiatric disorders. Conclusions: TNG youth with higher levels of GD also exhibited more severe anxiety, depression, suicidal ideation, and NSSI. Tailored interventions should be provided to prioritize relieving those with severe GD to protect TNG youth from psychiatric outcomes further.

Minority stress and mental health in European transgender and gender diverse people: A systematic review of quantitative studies

The current study aimed at systematically reviewing evidence on the relationships between gender minority stress and mental health outcomes among European transgender and gender diverse (TGD) individuals. A systematic search was conducted in PsycINFO, PubMED, Scopus, and Google Scholar. It was based on Boolean operators to combine terms related to minority stress, TGD identities, and mental health. Thirty studies were identified as eligible. The results confirmed that gender minority stress factors are significantly related with mental health problems among European TGD individuals. Distal stressors were identified as strongly associated with poorer mental health, with gender-related discrimination emerging as the most documented risk factor. The significant role of proximal stressors was also highlighted, with some mediation analyses detecting an indirect effect on mental health. However, identity concealment appeared unrelated to mental health outcomes. Resilience-promoting factors buffering the impact of stressors were also identified, including self-esteem, pride, transitioning, and social support. Conversely, data on community connectedness as a source of resilience were inconclusive. The studies reviewed have several limitations, including lack of longitudinal designs, sampling bias, variability in measurement methods, and unaccounted ethnic variables. Research and clinical recommendations in this field are reported.

An Analysis of the Demographics and Clinical Characteristics of Transgender and Intersex Populations in Korea: A Retrospective Study Using HIRA Database

BACKGROUND

Transgender and intersex populations have long remained under-documented in South Korea, largely due to the absence of comprehensive epidemiological data. With increasing societal acknowledgment, there's an urgent need to understand the demographics and health challenges faced by these communities.

METHODS

This retrospective, large-scale data study included people who received the F64 codes from the Korean Health Insurance Review & Assessment Service between January 2007 and December 2021. Demographics, gender-affirmative treatments, and psychiatric related medications were examined.

RESULTS

Between 2007 and 2021, 8,602 patients were diagnosed with "gender identity disorder" and 45 with "intersex." A steadily increasing annual prevalence was observed, peaking at 986 cases in 2021. The majority (79.8%) were aged between 10 and 30. Nearly half (53.2%) exhibited mental and behavioral disorders. Two-thirds had been prescribed anxiolytics or sedatives either before or after diagnosis. Merely 12.1% received hormone therapy covered by health insurance.

CONCLUSION

This is the first large-scale study highlighting the demographics and clinical characteristics of the transgender and intersex populations in Korea. The study reveals a consistent growth of these communities over the past 15 years, with a significant proportion under 30 years of age facing mental and behavioral challenges. Findings underscore the need for targeted healthcare interventions, early psychological support, and comprehensive insurance coverage tailored to the specific needs of these individuals in Korea.

Efficacy, safety, tolerability, and pharmacokinetics of long-acting injectable cabotegravir for HIV pre-exposure prophylaxis in transgender women: a secondary analysis of the HPTN 083 trial

BACKGROUND

The HIV Prevention Trials Network (HPTN) 083 trial showed that long-acting injectable cabotegravir was more effective than tenofovir disoproxil fumarate plus emtricitabine in preventing HIV in cisgender men and transgender women who have sex with men. We aimed to characterise the cohort of transgender women included in HPTN 083.

METHODS

HPTN 083 is an ongoing, phase 2b/3, randomised, multicentre, double-blind, double-dummy clinical trial done at 43 sites in seven countries (Argentina, Brazil, Peru, the USA, South Africa, Thailand, and Viet Nam). HIV-negative participants were randomly assigned (1:1) to receive injectable cabotegravir or tenofovir disoproxil fumarate plus emtricitabine. The study design and primary outcomes of the blinded phase of HPTN 083 have already been reported. An enrolment minimum of 10% transgender women was set for the trial. Here we characterise the cohort of transgender women enrolled from Dec 6, 2016, to May 14, 2020, when the study was unblinded. We report sociodemographic characteristics, use of gender affirming hormone therapy, and behavioural assessments of the transgender women participants. Laboratory testing and safety evaluations are also reported. The trial is registered at ClinicalTrials.gov, NCT02720094.

FINDINGS

HPTN 083 enrolled 570 transgender women (304 tenofovir disoproxil fumarate plus emtricitabine; 266 injectable cabotegravir). Transgender women were primarily from Asia (225 [39%]) and Latin America (205 [36%]); 330 (58%) reported using gender affirming hormone therapy. Intimate partner violence was common (270 [47%] reported emotional abuse and 172 [30%] reported physical abuse) and 323 (57%) reported a history of childhood sexual abuse. 159 (28%) transgender women disagreed that they were at risk for HIV, and 142 (25%) screened positive for depressive symptoms. During study follow-up, incidence of syphilis was 16·25% (95% CI 13·28-19·69), rectal gonorrhoea was 11·66% (9·14-14·66), and chlamydia was 20·61% (17·20-24·49). Frequency of adverse events was similar between the treatment groups. Nine seroconversions occurred among transgender women during the blinded phase of the study (seven in the tenofovir disoproxil fumarate plus emtricitabine group and two in the injectable cabotegravir group); overall incidence was 1·19 per 100 person-years (95% CI 0·54-2·25): 1·80 per 100 person-years (0·73-3·72) in the tenofovir disoproxil fumarate plus emtricitabine group and 0·54 per 100 person-years (0·07-1·95) in the injectable cabotegravir group (hazard ratio 0·34 [95% CI 0·08-1·56]). Cabotegravir concentrations did not differ by gender affirming hormone therapy use.

INTERPRETATION

HIV prevention strategies for transgender women cannot be addressed separately from social and structural vulnerabilities. Transgender women were well represented in HPTN 083 and should continue to be prioritised in HIV prevention studies. Our results suggest that injectable cabotegravir is a safe and effective pre-exposure prophylaxis option for transgender women.

FUNDING

National Institute of Allergy and Infectious Diseases and ViiV Healthcare.

Depression, Anxiety, and Stress among the Malay Muslim Transgender Women in Northern Malaysia: A Mixed-Methods Study

The study aimed to determine the prevalence and associated factors of depression, anxiety, and stress among the Malay Muslim transgender women in the northwestern states of Peninsular Malaysia. This mixed-method, quantitative and qualitative, study was conducted in collaboration with a nongovernmental organization that works incognito to advocate and help transgender women. Participants were recruited using a snowball method. A self-administered questionnaire was used that included information related to the demographic background of participants, and the Depression, Anxiety and Stress Scale and Oslo-3 Social Support Scale. For the qualitative part of the study, 13 in-depth interviews were conducted using a semi-structured interview guide in the Malay language. The study showed the prevalence of depression, anxiety, and stress was 33.3% (n = 47), 48.2% (n = 68), and 26.2% (n = 37), respectively. Difficulty in finding employment was significantly associated with depression, anxiety, and stress, whereas a history of physical abuse was also significantly associated with anxiety, and being ostracized by friends was significantly associated with depression. During in-depth interviews, suicidal thoughts were mentioned by several respondents and many lamented poor support from family and cisgender friends, and they complained of societal pressure. In addition to being physically and verbally abused, some also complained about cyberbullying. There is an urgent need to identify those with mental distress among transgender women in Malaysia to enable early interventions. More research is needed to identify mental health issues among transgender women and highlight these issues to sensitize the general public to their problems.

An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay

BACKGROUND

Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery.

METHODS

A total of 79 patients who underwent single-stage facial feminization surgery before (n = 38) or after (n = 41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes.

RESULTS

Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p < 0.001), reported lower pain scores (2.5 ± 1.8 versus 3.7 ± 1.6, p = 0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1] h, p < 0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery.

CONCLUSIONS

The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.

Suicidality and protective factors among sexual and gender minority youth and adults in Canada: a cross-sectional, population-based study

BACKGROUND

Sexual and gender minority populations experience elevated risks for suicidality. This study aimed to assess prevalence and disparities in non-fatal suicidality and potential protective factors related to social support and health care access among sexual and gender minority youth and adults and their heterosexual and cisgender counterparts in Canada. The second objective was to examine changes in the prevalence of suicidal ideation and protective factors during the COVID-19 pandemic.

METHODS

Pooled data from the 2015, 2016 and 2019 Canadian Community Health Surveys were used to estimate pre-pandemic prevalence of suicidal ideation, plans and attempts, and protective factors. The study also estimated changes in the prevalence of recent suicidal ideation and protective factors in fall 2020, compared with the same period pre-pandemic.

RESULTS

The prevalence of suicidality was higher among the sexual minority populations compared with the heterosexual population, and the prevalence was highest among the bisexual population, regardless of sex or age group. The pre-pandemic prevalence of recent suicidal ideation was 14.0% for the bisexual population, 5.2% for the gay/lesbian population, and 2.4% for the heterosexual population. The prevalence of lifetime suicide attempts was 16.6%, 8.6%, and 2.8% respectively. More than 40% of sexual minority populations aged 15-44 years had lifetime suicidal ideation; 64.3% and 36.5% of the gender minority population had lifetime suicidal ideation and suicide attempts. Sexual and gender minority populations had a lower prevalence of protective factors related to social support and health care access. The prevalence of recent suicidal ideation among sexual and gender minority populations increased in fall 2020, and they tended to experience longer wait times for immediate care needed.

CONCLUSIONS

Sexual and gender minority populations had a higher prevalence of suicidality and less social support and health care access compared to the heterosexual and cisgender populations. The pandemic was associated with increased suicidal ideation and limited access to care for these groups. Public health interventions that target modifiable protective factors may help decrease suicidality and reduce health disparities.

Difference in Psychiatric Hospital Admissions Between Cisgender and Transgender and Gender Nonconforming Youth, Before and During the Start of the COVID-19 Pandemic

This retrospective study of 1101 children and adolescents examines differences in psychiatric admissions between cisgender and transgender/gender nonconforming (TGNC) youth between June 2018 and November 2021. Sociodemographic and clinical characteristics for each admission were extracted from medical records. We compared proportion of total admissions and clinical characteristics between cisgender and TGNC youth, during specified time frames of pre-COVID-19, during quarantine, and post-quarantine. During quarantine, 294 (89.9%) youth identified as cisgender and 33 (10.1%) youth identified as TGNC. Post-quarantine, 205 (88.4%) youth identified as cisgender and 27 (11.6%) identified as TGNC. TGNC patients had more history of mood disorders (p < 0.001), self-injurious behavior (p < 0.001), and suicide attempt (p = 0.007), whereas cisgender patients had more history of Attention-deficit/Hyperactivity Disorder (ADHD) (p = 0.011) and violence (p < 0.001) across each time frame of the study. TGNC patients were more likely to be admitted due to suicidal ideation (p = 0.003), whereas cisgender patients were more often admitted for aggression (p < 0.001). There was no change across COVID-19 time periods in terms of any psychiatric history variable among patients identifying as TGNC. The proportion of admitted youth identifying as TGNC increased by 8.1% from pre-COVID-19 to post-quarantine (p < 0.001). These findings suggest that TGNC youth might be particularly vulnerable to mental health crises when faced with pandemic-related stressors. Further research on the vulnerabilities of TGNC youth during sudden and extreme social changes and how this can impact their mental health is necessary, as global pandemics could and are anticipated to repeat.

Transgender Dehumanization and Mental Health: Microaggressions, Sexual Objectification, and Shame

Using structural equation modeling in a national, nonprobabilistic sample of 292 transgender women and men, this project extends the pantheoretical dehumanization framework by testing direct and indirect relations between dehumanization (i.e., a higher-order construct from experiences of transgender microaggressions and sexual objectification), internalization processes (i.e., internalized transnegativity, self-objectification), shame, and general mental health. The model explained 55% of the variance in general mental health. Direct relations between dehumanization and all internalization processes were positive and significant. Internalized transnegativity and shame were significant, negative, direct predictors of mental health, but neither dehumanization nor self-objectification was a significant direct predictor of transgender mental health. Both self-objectification and internalized transnegativity directly predicted more feelings of shame. However, only shame yielded a significant indirect pathway from dehumanization to mental health. The indirect relations from self-objectification and internalized transnegativity to mental health through shame were significant. Research, advocacy, and clinical implications are discussed.

The Effect of Gender-Affirming Hormones on Gender Dysphoria, Quality of Life, and Psychological Functioning in Transgender Individuals: A Systematic Review

Gender-affirming hormone therapy (GAHT) is an essential part of gender affirmation for many transgender (including people with binary and nonbinary identities) individuals and although controlled studies are unethical, there remains limited evidence on the impact of GAHT on gender dysphoria, quality of life (QoL), and psychological functioning. Some clinicians and policy makers use the lack of evidence to argue against providing gender-affirming care. The aim of this review is to systematically and critically assess the available literature on the influence of GAHT on improving gender- and body-related dysphoria, psychological well-being, and QoL. Using Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, we searched Ovid MEDLINE®, Embase®, and Ovid PsycINFO® from inception to March 6, 2019 to assess the influence of GAHT on (1) gender dysphoria, (2) body uneasiness, (3) body satisfaction, (4) psychological well-being, (5) QoL, (6) interpersonal and global functioning, and (7) self-esteem. Our search strategy found no randomized controlled trials. Ten longitudinal cohort studies, 25 cross-sectional studies, and 3 articles reporting both cross-sectional and longitudinal data were identified. While results are mixed, the majority of studies demonstrate that GAHT reduces gender dysphoria, body dissatisfaction, and uneasiness, subsequently improving psychological well-being and QoL in transgender individuals. However, all current researches are of low to moderate quality comprising longitudinal cohort studies and cross-sectional studies, making it difficult to draw clear conclusions and do not reflect external social factors unaffected by GAHT, which significantly impact on dysphoria, well-being, and QoL.

Social Stressors and Health Among Older Transgender and Gender Diverse Veterans

Purpose: Health disparities in transgender and gender diverse (TGD) veterans compared with cisgender veterans have been documented. However, there is a paucity of literature focused on older TGD veterans. We assessed health conditions and social stressors in older TGD veterans compared with matched cisgender veterans. Methods: Using gender identity disorder diagnosis codes, we identified 1244 TGD veterans (65+ years of age) receiving care in the Veterans Health Administration (VHA) from 2006 to 2018. These TGD veterans were then matched to 3732 cisgender veterans based on age, VHA site, and date of care in VHA. Results: In adjusted models, TGD veterans compared with cisgender veterans were less likely to have alcohol use disorder (adjusted odds ratio [AOR; 95% confidence interval]: [0.70; 0.58-0.85]), drug use disorder (0.59; 0.47-0.74), tobacco use (0.75; 0.65-0.86), and anxiety (0.74; 0.62-0.90). However, compared with cisgender veterans, TGD veterans were more likely to experience depression (1.63; 1.39-1.93), Alzheimer's disease (8.95; 4.25-18.83), cancer (1.83; 1.56-2.14), violence (1.82; 1.14-2.91), social/familial problems (2.45; 1.99-3.02), lack of access to care/transportation (2.23; 1.48-3.37), and military sexual trauma (2.59; 1.93-3.46). Furthermore, compared with cisgender veterans, TGD veterans were more likely to have documentation of a higher count of social stressors: 1 or more stressors (1.64; 1.38-1.95) and 2 or more stressors (1.22; 1.01-1.49). Conclusion: Despite significant disparities in social stressors and health conditions compared with cisgender veterans, TGD veterans had a lower likelihood of substance use and anxiety. Interventions are needed to mitigate social stressors and improve health among the older TGD veteran population.

A Longitudinal Study Exploring the Role of Mental Health Symptoms and Social Support Regarding Life Satisfaction 18 Months after Initiation of Gender-Affirming Hormone Treatment

While positive changes in mental health have been found following gender-affirming hormone treatment (GAHT), it is unclear how pre-GAHT mental health and social support can influence treatment outcomes. To address this, a retrospective longitudinal design was used in which 137 participants completed measures of social support, anxiety, and depression prior to GAHT (T0) and a measure of life satisfaction 18 months after GAHT (T1). The data showed no significant differences in life satisfaction at T1 based on T0 caseness of anxiety or depression. It was also found that T1 life satisfaction was not predicted by levels of anxiety, depression, or social support at T0. The lack of significant differences in life satisfaction at 18 months post-GAHT based on pre-GAHT mental health, coupled with no evidence for the predictive role social support suggest that these factors are not central to long-term life satisfaction. For many, lower mental wellbeing may be part of the experience of awaiting GAHT and should not be regarded as indicative of longer-term issues. Instead, facilitation of social support connections and mental health support should be offered both concurrently with, and for those awaiting, GAHT.

Psychosocial Problems and Condomless Anal Sex among Transgender Women in Two Cities of China: Study Based on the Syndemic Framework

Studies examining the association between psychosocial problems and condomless anal sex (CAS) among transgender women (TGW) are rare. In this study, close attention was paid to the effect of co-occurring psychosocial problems on sexual risk behaviors. A cross-sectional study, including 247 TGW, was conducted in Kunming and Shenyang, China. The prevalence of condomless anal sex among TGW in the previous 6 months was 30.8%. Most of the psychosocial factors were associated with one another in bivariate logistic regression models. Low self-esteem (ORm = 2.99, 95% CI = 1.25-7.18), sexual compulsivity (ORm = 2.13, 95% CI = 1.13-4.00), and intimate partner violence (ORm = 2.21, 95% CI = 1.19-4.11) were discovered to be related to condomless anal sex in the multivariate regression model. No significant interactive effects of the syndemic factors on condomless anal sex were detected. More programmatic and effective HIV prevention interventions targeting psychosocial problems are required to reduce HIV infection within the population.

[Modalities of gynecological follow-up of transgender patients - Literature review]

Transgender patients are at increased risk of cancer, sexually transmitted diseases, short- and long-term postoperative complications in patients with vaginoplasty, but also unwanted pregnancy in non-hysterectomized trans men. However, access to care is often difficult for these patients, who often do not benefit from appropriate gynecological monitoring, especially for fear of judgment or discrimination. In view of the health risks of these patients, it is essential to be able to offer them specific and adapted gynecological follow-up. To date, there are no clear recommendations regarding the gynecological follow-up of transgender patients. We relied on the recommendations of the World Professional Association of Transgender Health (W-PATH) and the Endocrine Society Guideline and performed a literature review. We carried out several searches via pubmed in order to explore one by one the different aspects of gynecological follow-up, in particular of non-hysterectomized transgender men and transgender women with a vaginoplasty. It emerges from this a lack of follow-up of transgender people, with a reluctance to consult a gynecologist, associated with the lack of knowledge and experience of health professionals. Due to the risks identical to those of the general population, added to those specific to transgender people, it is important to be able to offer these patients specialized and personalized gynecological follow-up, and to raise awareness and train health professionals on the importance of and the specificities of the gynecological follow-up of these patients.

Mental Distress and Use of Stimulants: Analysis of a Longitudinal Cohort of Transgender Women

Purpose: The purpose of our study was to examine the effects of mental distress (depression, anxiety, and post-traumatic stress disorder [PTSD]), incarceration, and hate crime on stimulant use (methamphetamine, crack, and cocaine) among transgender women. Methods: We conducted a secondary analysis of longitudinal data collected from 2016 to 2018 with 429 transgender women in the San Francisco Bay Area. Generalized estimating equation log-binomial regressions were used to calculate relative risks of stimulant use associated with mental distress, incarceration, and hate crime. Results: At baseline, transgender women experienced transphobic hate crime (46.4%), incarceration (53.0%), mental distress (69.2%), and stimulant use (28.4%). Transgender women who used stimulants reported lower education (45.1%, χ² = 14.3, p = 0.001) and significantly more had been incarcerated (62.3%, χ² = 5.9, p = 0.015), and reported diagnoses of depression (67.8%, χ² = 6.1, p = 0.014), anxiety (62.8%, χ² = 4.3, p = 0.039), and PTSD (43.8%, χ² = 6.7, p = 0.010). Longitudinal multivariate analysis found that depression (adjusted relative risk [aRR] = 1.46, 95% confidence interval [CI] 1.09-1.95), anxiety (aRR = 1.42, 95% CI = 1.05-1.93), and PTSD (aRR = 1.38, 95% CI = 1.02-1.87) were associated with methamphetamine use but not with crack or cocaine use. Incarceration was associated with methamphetamine use and crack use, whereas experiencing hate crime was associated with crack use. Conclusions: Mental distress, incarceration, and hate crime were key exposures of stimulant use among transgender women. Intervention targets for reducing stimulant use should consider working upstream by addressing underlying stressors impacting mental health for transgender women, including laws to protect transgender women from hate crime and to reduce their disproportionate representation in the criminal justice system.

(Dis)advantaged positions in accessing gender-affirming healthcare in Finland: an intersectional qualitative study of foreign-origin transgender people

BACKGROUND

An increasing body of scholarship focuses on transgender individuals' experiences when accessing gender-affirming healthcare. However, the experiences of transgender individuals who identify as being of foreign-origin in Finland have rarely been studied. This study aims to fill the gap in research and contribute to the understanding of the experiences of transgender individuals who also identify as belonging to the foreign-origin populations in Finland.

METHODS

Fourteen semi-structured qualitative interviews were conducted and analyzed with reflexive thematic analysis (RTA), through the framework of intersectionality. The interviews were part of a broader sample of qualitative data, collected about the experiences of sexual and gender minorities among the foreign-origin populations in Finland.

RESULTS

The analysis showed two main interconnected themes. Firstly, perceived barriers when accessing gender-affirming care. In this theme, the intersections of transgender identity, foreign background, class, and age affected the experiences of the individuals. Secondly, the necessity of "performing identities:" the intersections of class, transgender identity, nativity, and race affected those.

CONCLUSION

The findings of the current study suggest that the intersectional aspects of individual identities create structural inequalities in the Finnish gender-affirming healthcare system. To tackle these inequalities, further research is needed on the healthcare experiences of gender minorities in Finland both within and outside the scope of transgender-specific healthcare.

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults

Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.

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.

Associations Between Gender Identity Control, Gender Identity Non-Verification, and Health Risks among Trans Women of Color Living with HIV

This study applied Identity Theory (IT) metrics to data gathered from a sample of trans women of color living with HIV to determine whether measures of identity control and/or identity non-verification were associated with trans women's self-reported health risks. From February 2014 through August 2016, 139 HIV-positive trans women were enrolled. Cross-sectional time-series regressions indicated that identity control and identity non-verification were both associated with self-reported behavioral and health outcomes. Increased gender identity control was associated with decreased drug and alcohol use (multiple Logit [L]; all p < .05) and decreased likelihood of self-reported infection with a sexually transmitted infection (STI; multiple L; all p < .05); increased perceived identity non-verification was associated with increased severity of depression symptoms (b = 0.09) as well as increased odds of engagement in exchange sex (L = 0.32), increased drug and alcohol use (multiple L p > .05), and increased likelihood of self-reported infection with viral STIs (Lgenital warts = 0.49; Lherpes = 0.69). These findings indicate IT may be a useful theoretical framework through which to understand and analyze behavior among trans women of color living with HIV. Identity verification dynamics in particular may be useful mechanisms to explain engagement in several potentially harmful behaviors.

Barriers and Motives for Physical Activity and Sports Practice among Trans People: A Systematic Review

This study aimed to analyze the research conducted between 2016 and 2021, regarding barriers and motives for the practice of physical activity (PA), physical exercise (PE), and sports among trans individuals. The searches were carried out in the PubMed, Scopus, and Web of Science databases between January 2022 and April 2022, and included papers published between October 2016 and December 2021. After reading the full text of the studies, and according to the eligibility criteria previously defined, only six studies met the inclusion criteria. Internal barriers were related to body dissatisfaction and discomfort, discrimination, and fear of other people’s reactions. Regarding external barriers, sports environment, PE environment, and sports participation policies and regulations are the main factors expressed by trans individuals that hinder the practice of sports and PE. The desire to achieve a specific physical form and the role that PE plays in the preparation and/or replacement of gender-confirming surgery are the most important motives for the practice. This study highlights the importance of continuing to fight the barriers encountered in the practice of PE and sports, suggesting the main motives that could help create better interventions, plans, and inclusive policies that may help promote its practice.

Educational preparedness to care for transgender and gender diverse adults: Perspectives of mental health professionals

Ensuring that mental health professionals are appropriately trained to provide affirming and sensitive care to transgender and gender diverse (TGD) adults is one mechanism that may reduce the marginalization sometimes experienced by TGD adults in mental health contexts. In this study, mental health professionals (n=142) completed an online survey documenting the sources and types of training received to provide TGD-sensitive care; and, shared a self-assessment of their comfort, competence, and ability to provide TGD-sensitive care. Findings revealed that the majority of the mental health professionals in the study (approximately 81%) received specific training to work with TGD clients from a variety of sources. These mental health professionals also self-reported high levels of comfort, competence, and ability to offer TGD-sensitive care which were statistically significantly associated with the number of hours of TGD-specific training they had received.

Substance Use in the Transgender Population: A Meta-Analysis

(1) Background: This meta-analysis aimed to assess the relationship between identifying as transgender and substance use. (2) Methods: We searched for relevant studies in PubMed, Scopus, the Web of Science, and PsycINFO on 21 July 2021. (3) Results: Twenty studies comparing transgender and cisgender people were included in this work, accounting for a total of 2,376,951 participants (18,329 of whom were transgender). These articles included data on current tobacco use, current tobacco use disorder, current alcohol use, current alcohol use disorder, lifetime substance (all) use, current substance use (excluding tobacco and alcohol), current use of specific substances (excluding tobacco and alcohol and including cocaine, amphetamines, methamphetamines, ecstasy, stimulants, heroin, opiates, cannabis, marijuana, LSD, hallucinogens, steroids, inhalants, sedatives, Ritalin or Adderall, diet pills, cold medicine, prescription medications, polysubstance, other club drugs, and other illegal drugs), and current substance use disorder (excluding tobacco and alcohol). We used the ORs and their 95% CIs to state the association between identifying as transgender and those variables. The control reference category used in all cases was cisgender. We employed a random-effects model. Transgender people were more likely to use tobacco (odds ratio (OR) = 1.65; 95% CI [1.37, 1.98]), have used substances throughout their lives (OR = 1.48; 95% CI [1.30, 1.68]), and present current use of specific substances (OR = 1.79; 95% CI [1.54, 2.07]). When current alcohol and substance use in general and tobacco, alcohol, and substance use disorders specifically were considered, the likelihood did not differ from that of cisgender people. (4) Conclusions: The presence of substance use disorders did not differ between transgender and cisgender people. Considering this population as consumers or as addicted may be a prejudice that perpetuates stigma. Nonetheless, transgender people were more likely to use tobacco and other substances, but not alcohol. Hypothetically, this might be an emotional regulation strategy, a maladaptive mechanism for coping with traumatic experiences, or could respond to minority stress, produced by stigma, prejudice, discrimination, and harassment. It is of particular importance to implement policies against discrimination and stigmatisation and to adapt prevention and treatment services so that they are inclusive of the 2SLGBTQIA+ community.

Family-Based Interventions with Transgender and Gender Expansive Youth: Systematic Review and Best Practice Recommendations

Research on transgender and gender expansive (TGE) youth has highlighted the disproportionate and challenging mental health and developmental outcomes faced by these young people. Research also largely suggests that family acceptance of TGE youth's gender identity and expression is crucial to preventing poor psychosocial outcomes in this community. Recently, family-based treatment has become common practice with TGE youth whose families are available for care, but it is unclear whether research provides outcome data for family interventions with TGE youth. This study follows Preferred Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically review articles that provide outcome data or clinical recommendations for family-based interventions with TGE youth and their families. No quantitative outcome data for family therapy with TGE youth were found, but numerous articles spanning decades (n=32) provided clinical practice recommendations for family-based interventions with this population. Very few articles provided outcome data for family therapy with sexual minority youth (n=2). Over time, clinical strategies have moved from pathologizing to affirming of TGE youths' gender journey. Common clinical strategies of affirming interventions include (1) providing psychoeducation, (2) allowing space for families to express reactions to their child's gender, (3) emphasizing the protective power of family acceptance, (4) utilizing multiple modalities of support, (5) giving families opportunities for allyship and advocacy, (6) connecting families to TGE community resources, and (7) centering intersectional approaches and concerns. Future research should examine the efficacy of family-based interventions that incorporate these clinical strategies and collect quantitative data to systematically determine their effect on psychosocial outcomes.

Childhood Gender Variance and the Autism Spectrum: Evidence of an Association Using a Child Behavior Checklist 10-Item Autism Screener

Childhood gender variance (GV) is associated with autism spectrum disorder (ASD) diagnosis/traits; however, this association has mainly been investigated in clinical samples. An ASD screening measure based on 10 items from the commonly used Child Behavior Checklist (CBCL) might enable investigation of this association in a wider variety of (non-clinical) populations where the CBCL and a measure of GV are available. We investigated whether GV in 6- to 12-year-olds (N = 1719; 48.8% assigned male at birth) from a community sample showed an association with the CBCL 10-item ASD screener. The Gender Identity Questionnaire for Children measured GV. The CBCL 10-item ASD screener measured ASD traits. The remaining CBCL items provided a measure of children's general emotional and behavioral challenges. Higher GV was associated with higher CBCL ASD screener scores, including when controlling for the remaining CBCL items. The CBCL 10-item ASD screener can be useful for investigating the link between GV and ASD traits in 6- to 12-year-olds. Given that the CBCL is commonly employed, secondary analyses of existing datasets that also included a measure of GV could enable investigation of how widely the association between GV and ASD applies across a variety of populations.

Clinical Presentation and Treatment Trajectory of Gender Minority Patients With Obsessive-Compulsive Disorder

Gender minorities experience unique minority stressors that increase risk for psychiatric disorders. Notably, gender minorities are four and six times more likely than their cisgender female and male peers, respectively, to be treated for or diagnosed with obsessive-compulsive disorder (OCD). Despite higher rates of OCD, more psychiatric comorbidities, and minority stressors, little is known about the clinical presentation and treatment outcomes of gender minorities with OCD. Using a sample of 974 patients in specialty treatment programs for OCD, the current study found that gender minorities reported more severe contamination symptoms and greater incidence of comorbid substance use/addiction, trauma/stressor-related, personality, and other/miscellaneous disorders compared to cisgender male and female patients. Despite significantly longer lengths of stay, gender minorities reported less symptom improvement across treatment compared to cisgender male and female patients. Findings underscore the need for continued research to improve the effectiveness and individualization of treatment for gender minorities with OCD.

Examining the Mental Health Presentations of Treatment-Seeking Transgender and Gender Nonconforming (TGNC) Youth

Recent research suggests that transgender and/or gender nonconforming (TGNC) youth present with heightened levels of mental health problems compared to peers. This study seeks to examine the mental health needs of a large sample of treatment-seeking TGNC youth by comparing them to cisgender males and females. Participants were 94,804 children and youth ages 4-18 years (M = 12.1, SD = 3.72) who completed the interRAI Child and Youth Mental Health Instrument (ChYMH) or Screener (ChYMH-S) at participating mental health agencies in the Ontario, Canada. Overall, the mental health presentations of TGNC youth were similar to cisgender females but at higher acuity levels. TGNC youth showed significantly higher levels of anxiety, depression, social disengagement, positive symptoms, risk of suicide/self-harm, and were more likely to report experiencing emotional abuse, past suicide attempts, and a less strong, supportive family relationship than cisgender females and males. Clinical implications of these findings are discussed.

Impact of the COVID-19 Pandemic on Perceptions of Health and Well-Being Among Sexual and Gender Minority Adolescents and Emerging Adults

Purpose: The study purpose was to examine how the COVID-19 pandemic may be differentially impacting the well-being of sexual and gender minority (SGM) youth compared with their non-SGM counterparts. Specifically, we looked at perceptions of mental and physical health impact and relevant aspects of coping with the pandemic such as engagement in prosocial activities that might ultimately promote resilience. Methods: Survey data were collected between November 27, 2020, and December 11, 2020, from 990 adolescents and emerging adults aged 13-23 years. Participants were recruited through advertisements on Facebook and Instagram with an effort to overrecruit SGM youth. Questions asked youth about their perception of the impact of the COVID-19 pandemic on their physical and mental health, the types of prosocial activities engaged in during the pandemic, and how they felt they were doing now versus before the pandemic. Results: SGM youth reported a significantly greater impact from the pandemic than non-SGM youth. Both SGM youth and cisgender heterosexual females reported greater impact on their mental health compared with cisgender heterosexual males, with cisgender sexual minority females and gender minority youth reporting the highest mental health impact. Gender minority youth also reported feeling less connected to their families and less safe at home as a result of the pandemic. Conclusion: Health professionals, educators, and advocates need to help assess SGM youth for negative impact from the pandemic and help them connect with other youth and support resources online as they move forward. Youth may also benefit from programs connecting them to volunteer work and neighbors.

Examining the elevated risk of COVID-19 in transgender communities with an intersectional lens

COVID-19 has presented unique and unprecedented struggles for all people, yet they tend to be magnified among marginalized communities. Indeed, in the United States, transgender (trans) people experience oppression in many facets of their lives, which places them at an increased risk for both COVID-19 exposure and complications. This oppression can be broadly categorized into two distinct, yet interrelated categories: health disparities (e.g., decreased immune health) and structural barriers (e.g., employment discrimination, policing). Recent scholarship has examined trans people’s risk for COVID-19 exposure and mortality, however few articles examine intersectional identities, and, to our knowledge, none have interrogated oppressive power structures (e.g., the prison industrial complex). We aim to fill these critical gaps and argue that it is imperative for cisgender people to partner with trans communities to dismantle these harmful systems, positively impacting the lives of trans individuals during the pandemic and beyond. We make several key recommendations for researchers, policymakers, healthcare workers, and allies to do so.

Sex, gender and gender identity: a re-evaluation of the evidence

In the past decade there has been a rapid increase in gender diversity, particularly in children and young people, with referrals to specialist gender clinics rising. In this article, the evolving terminology around transgender health is considered and the role of psychiatry is explored now that this condition is no longer classified as a mental illness. The concept of conversion therapy with reference to alternative gender identities is examined critically and with reference to psychiatry's historical relationship with conversion therapy for homosexuality. The authors consider the uncertainties that clinicians face when dealing with something that is no longer a disorder nor a mental condition and yet for which medical interventions are frequently sought and in which mental health comorbidities are common.

Healthcare for Trans*gender People in Germany: Gaps, Challenges, and Perspectives

People whose gender does not correspond to the binary gender system, i.e., trans∗gender people, face two main problems when it comes to healthcare in Germany: (1) They often suffer from general psychiatric comorbidities as well as specific and significant mental distress due to gender dysphoria, and (2) the German healthcare system lacks sufficiently educated and clinically experienced medical personnel who are able to provide specialized healthcare. Aside from transition, it often is extremely difficult for trans∗gender people to get access to and be integrated into the medical system. Stigmatization and pathologization in treatment are widespread, as are long waiting times for specialized healthcare providers who are often only accessible to those trans∗gender people willing to travel long distances. Frequently, trans∗gender people face further difficulties and barriers after transition, as some healthcare professionals fail to provide suitable care (e.g., gynecological consultation for transmen). The ICD-11 German Modification (ICD-11-GM), which should be routinely used by 2022, implements a depathologization of trans∗gender people in the medical system. This paper compares the issues related to health and healthcare of trans∗gender people in Germany with those in other European countries. We review the care offered by specialized centers with regard to treatment of and support for trans∗gender people. We conclude with specific proposals that may contribute to establish an improved, up-to-date, gender-sensitive healthcare system.

Anxiety and Depression Among Transgender People: Findings from a Cross-Sectional Online Survey in Russia

Purpose: As we still do not know enough about the mental health concerns of gender minority people in Russia, there is a need to initiate research on these issues. We aimed to examine the frequency of anxiety and depression symptoms in a Russian sample of transgender people. Methods: The study consisted of a structured online survey and was conducted throughout November 2019. The Hospital Anxiety and Depression Scale was used for online screening of anxiety and depression symptoms. A total of 588 transgender adults living in all Federal Districts of Russia (mean age 24.0 ± standard deviation 6.7) was included in the final analysis. Results: It was found that 45.1% (n = 265) and 24.0% (n = 141) of transgender people had clinically significant levels of anxiety and depression, respectively. No statistically significant differences in the prevalence of anxiety and depression were found among those who identified as a transgender man, a transgender woman, or other transgender identities. The anxiety and depression mean scores in the sample were statistically significantly higher than in the general Russian population (p < 0.001). No statistically significant differences were found in the level of depression and anxiety symptoms among respondents in Moscow, St. Petersburg, and other Russian cities. Conclusions: We found high rates of clinical symptoms of depression and anxiety among transgender people, consistent with international research. The study highlights the need for further research on the psychological well-being and mental health of transgender people, and the availability of psychiatric care to transgender people living in Russia.

Deconstructing cissexism: The journey of becoming an affirmative family therapist for transgender and nonbinary clients

This article proposes a model for family therapists to become more competent, inclusive, and affirmative in their clinical work with transgender and nonbinary clients. In particular, this article details: (1) barriers to transgender and nonbinary affirmative therapy, (2) impacts of these barriers on transgender and nonbinary people's mental health, (3) a three-step model for becoming an affirmative therapist for transgender and nonbinary clients, and (4) strategies for deconstructing cissexism in therapy. This goal of this article is to invite family therapists to join in on a lifelong journey of "becoming" an affirmative therapist for transgender and nonbinary clients, a journey on which none of us will ever "arrive". We can, however, take continual action to minimize the negative impacts of cissexism on therapists and clients; this article offers ideas for a place to start.

Childhood transgenderity under the perspective of elementary school teachers

OBJECTIVE

to analyze teachers' conceptions about transgenderity in childhood and to identify the possibilities and limits of working with these children in the school context.

METHOD

a qualitative research study, carried out with 23 teachers from two municipal elementary schools. Semi-structured interviews were used to produce empirical material. As an analytical resource, the content analysis technique, thematic modality, was used.

RESULTS

six thematic categories emerged in the set of empirical material: There is transgenderity in childhood; The construction of gender identity and roles in childhood; The experience of trans children in the school context; Trans children: How to deal with?; Discussing the differences in the classroom: Is this the way?; and Dilemmas of school and family interaction. It was found that the gender dichotomy is reinforced in the classroom, causing tensions and stereotyped divisions for male and female roles. Various forms of violence have been reproduced by classmates and teachers, who, due to lack of knowledge or to unpreparedness, reinforce concepts and attitudes that lead to the maintenance of exclusion.

CONCLUSION

the schools find it difficult to promote the inclusion of trans children. It is necessary to create strategies aimed at raising awareness and training the professionals who make up the school environment, especially teachers in the initial grades.

Social relationship experiences of transgender people and their relational partners: A meta-synthesis

RATIONALE

Social relationships are important in bolstering health and well-being for everyone in the general population. For transgender people, strong supportive social relationships may be paramount to their overall health and well-being due to their marginalised status in society.

OBJECTIVE

This review aimed to investigate what is currently known about the social relationship experiences of transgender people and their relational partners (e.g., family members, romantic partners).

METHODS

Thirty-nine qualitative papers were extracted from Web of Science, Scopus, Cochrane, and PubMed that related to social relationships of transgender people. These papers were analysed via a qualitative meta-synthesis.

RESULTS

Forty-nine second-order themes were identified, initially organised into relational partner clusters (e.g., family, friends, work colleagues) for specific phenomena, then these were synthesized into five overarching conceptual themes: (1) Development of relationships through transition and beyond, (2) Coping strategies of transgender people and their relational partners, (3) Reciprocal support in social relationships, (4) Stigma enacted and ameliorated interpersonally, and (5) Influence of stigma on social health and well-being.

DISCUSSION AND CONCLUSIONS

These overarching themes show the potential characteristics that assist in the health-buffering role of social relationships for transgender people and their relational partners. Of particular note, stigma was reported as a common negative experience by transgender people and their relational partners, and open communicative social relationships had positive effects on self-conceptualisations of identity, which were inferred to protect against the damaging effects of stigma. We discuss the various implications and applications of this meta-synthesis to future research and clinical settings as well as how it can inform healthcare policy to support transgender people.

Mental Health and Health Risk Behaviors of Active Duty Sexual Minority and Transgender Service Members in the United States Military

Purpose: The aim of this study was to examine health risk behaviors and mental health outcomes among sexual minority and transgender active duty military service members and their heterosexual and cisgender counterparts. Methods: Participants (N = 544) were recruited by using respondent-driven sampling between August 2017 and March 2018 and completed an online survey by using validated measures of cigarette smoking, alcohol use, anxiety, depression, post-traumatic stress disorder (PTSD), and suicidality. Bayesian random intercept multiple logistic regressions were used to understand differences between sexual minority participants and heterosexual participants as well as between transgender participants and both their cisgender sexual minority and cisgender heterosexual peers. Results: Cisgender sexual minority women service members were more likely to meet criteria for problematic alcohol use (adjusted odds ratio [aOR] = 10.11) and cigarette smoking (aOR = 7.12) than cisgender heterosexual women. Cisgender sexual minority men had greater odds of suicidality (aOR = 4.73) than their cisgender heterosexual counterparts. Transgender service members had greater odds of anxiety, PTSD, depression, and suicidality than their cisgender peers. Conclusion: Military researchers and policymakers who seek to improve the overall health and well-being of sexual minority and transgender service members should consider programs and policies that are tailored to specific health outcomes and unique sexual minority and transgender subgroups.

Workplace support and affirming behaviors: Moving toward a transgender, gender diverse, and non-binary friendly workplace

Background: The experiences of transgender, gender diverse, and non-binary (TGDNB) workers remain poorly understood and under-examined in the extant literature, with workplace support perceptions and affirming behaviors of these workers particularly misunderstood. Aims: We address this gap in the literature by presenting and empirically testing a theoretical model that suggests affirming behaviors are differentially related to various sources of TGDNB worker support. We further suggest these sources of support are differentially related to TGDNB employee satisfaction and gender identity openness at work. Methods: We collected data from trans-related social media groups, inviting TGDNB-identifying employees to participate in the study. Quantitative and qualitative data from 263 TGDNB employees were collected through survey administrations. Results: Supervisor and coworker support are related to job and life satisfaction, with supervisor support strongly connected to job satisfaction. The use of gender-affirming pronouns/titles and discouraging derogatory comments at work were related to perceived TGDNB support. Positive transgender organizational climate was strongly related to gender identity openness at work. Discussion: Results highlight a need for better workplace inclusivity and TGDNB-friendly environments, as well as more diversity training and company policy improvements that directly impact the workplace experiences of TGDNB people.

Reduction of Gender Identity Stigma and Improvements in Mental Health Among Transgender Women Initiating HIV Treatment in a Trans-Sensitive Clinic in Argentina

Purpose: Stigma toward transgender women (TGW) increases psychosocial vulnerability, leading to poor mental health and affecting access and retention in HIV care. Trans-sensitive health care (TSHC) has the potential to mitigate this adverse impact. This study aimed to describe baseline characteristics in gender identity stigma (GIS), mental health, and substance use among TGW living with HIV initiating antiretroviral treatment and to analyze changes after 6 months in HIV care in a TSHC clinic in Argentina. Methods: Sixty-one TGW living with HIV responded to the following questionnaires at baseline and after 6 months in TSHC: sociodemographic, experiences of GIS (in health care, police, etc.), Center for Epidemiologic Studies Depression Scale (CES-D) (depression), State Trait Anxiety Inventory (STAI) (anxiety), Drug Abuse Screening Test (DAST-10) (drug use), Alcohol Use Disorders Identification Test (AUDIT) (alcohol use), 8-item Personal Wellbeing Index-Adults (PWI-A) (quality of life [QOL]), Personality Inventory for DSM-5-Brief Form (PID-5-BF) (maladaptive personality traits), and Duke Index (social support). Analyses included Pearson correlations to analyze associations between variables; and paired sample t-tests, to explore changes between baseline and 6 months. Results: A significant proportion experienced episodes of GIS the last year in any context. At baseline, 50.8% showed significant depressive symptoms and 65.6% reported any drug use in the last year. At 6 months, participants experienced a significant reduction of GIS, both enacted and internalized, anxiety, drug, and alcohol use, and improvement in QOL. The remaining mental health indicators were not significantly modified. Conclusion: A TSHC service may have a gender-affirmative impact on TGW initiating HIV care that contributes to reduce GIS and substance use and improve mental health. This highlights the importance that HIV care programs for TGW comply with trans-sensitive essential components to enhance retention.

Predicting outcomes of cross-sex hormone therapy in transgender individuals with gender incongruence based on pre-therapy resting-state brain connectivity

Individuals with gender incongruence (GI) experience serious distress due to incongruence between their gender identity and birth-assigned sex. Sociological, cultural, interpersonal, and biological factors are likely contributory, and for some individuals medical treatment such as cross-sex hormone therapy and gender-affirming surgery can be helpful. Cross-sex hormone therapy can be effective for reducing body incongruence, but responses vary, and there is no reliable way to predict therapeutic outcomes. We used clinical and MRI data before cross-sex hormone therapy as features to train a machine learning model to predict individuals' post-therapy body congruence (the degree to which photos of their bodies match their self-identities). Twenty-five trans women and trans men with gender incongruence participated. The model significantly predicted post-therapy body congruence, with the highest predictive features coming from the cingulo-opercular (R² = 0.41) and fronto-parietal (R² = 0.30) networks. This study provides evidence that hormone therapy efficacy can be predicted from information collected before therapy, and that patterns of functional brain connectivity may provide insights into body-brain effects of hormones, affecting one's sense of body congruence. Results could help identify the need for personalized therapies in individuals predicted to have low body-self congruence after standard therapy.

Differential Experiences of Mental Health among Trans/Gender Diverse Adults in Michigan

Transgender and gender diverse individuals experience high rates of health disparities, as compared with their cisgender (non-transgender) counterparts. One area in which these disparities is most grave is that of mental health, with some studies indicating transgender and gender diverse individuals as having a 40% rate of lifetime suicide attempts and similarly high rates of depression, anxiety, and suicidal ideation. These rates vary further within this population, with differential rates seen across sociodemographic factors, including race/ethnicity, gender, sexual orientation, disability status, education level, and income. This study explores mental health experiences across different social identities, using data from the 2018 Michigan Trans Health Survey (N = 659), a community-based participatory action research project collected in Michigan, United States, analyzed using chi-square tests of independence and logistic regressions. Findings indicate incredibly high rates of mental health concerns; 72.2% had been diagnosed with depression in their lifetime and 73.0% had been diagnosed with anxiety in their lifetime. In the past year, 49.9% had had non-suicidal self-injury (NSSI) thoughts, 45.4% had suicidal thoughts, 26.3% engaged in NSSI, and 7.7% had attempted suicide. Bivariate regressions showed some nuanced experiences of rates of mental health diagnoses and experiences, such as greater odds of experiencing all mental health disparities among those with disabilities, and differential odds across gender in regard to ever having a depression diagnosis, non-suicidal self-injury thoughts and engaging in non-suicidal self-injury behavior. This indicates a need for social workers, counselors, therapists, and other human services professionals to act more intentionally and with an intersectional lens when it comes to exploring the mental health of transgender and gender diverse persons.