Navigating identity: Experiences of binary and non-binary transgender and gender non-conforming (TGNC) adults

Threads of Diversity: Exploring Clothing Experiences of India's LGBTQ Community

The LGBT community is a hidden population that has only recently started to integrate into mainstream society in India. Though the community has been studied extensively, the clothing of its members has not received the same attention as other fields. Present study was planned with the objective to ascertain the community's struggles with clothing in India. Both primary and secondary data were utilized for this purpose. A systematic Review of Literature was carried out to explore the previous studies in this field. This was followed by primary data collection. Eleven participants- six gay men, three transgender women, one pansexual woman and one bisexual man were recruited through snowball sampling and participated in telephonic interviews. Based on the content analyses, three themes were established; (1) Creation and expression of gender/sexual identity through clothing (2) Identification and procurement of clothing and (3) Need for acceptance and integration through Fashion and Media. Specific issues related to clothing along with certain clothing practices of the LGBT community were successfully observed in the present study.

New insights into the goals of transgender male versus non-binary individuals considering metoidioplasty and phalloplasty gender-affirming surgery

BACKGROUND

Understanding patient goals for metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) is paramount to achieving satisfactory, preference-sensitive outcomes, yet there is a lack of understanding of MaPGAS priorities and how these may vary between transgender men and non-binary individuals assigned female at birth (AFAB).

AIM

To understand the surgical goals of transgender men and non-binary individuals AFAB considering MaPGAS.

METHODS

An online survey was created following literature review and qualitative interviews and distributed via social media and a community health center to participants AFAB aged ≥18 years who had considered but not yet undergone MaPGAS. We collected demographics, surgical history, Likert ratings of importance of 14 possible MaPGAS goals, and selection of the 5 most important goals. Differences in goal importance ratings were compared using the Mann-Whitney U test. Responses to an open-ended question on additional MaPGAS goal considerations were thematically analyzed by 2 reviewers.

OUTCOMES

A total of 248 eligible participants completed the survey; participants included transgender men (64%) and non-binary individuals (36%).

RESULTS

Both groups rated maintaining tactile and erogenous sensations as top priorities. Significant differences emerged in half of the goals, with transgender men more likely to place importance on being seen as male, public restroom comfort, peeing through the tip of the penis, standing urination through the fly, and resolution of gender dysphoria. Non-binary individuals were more likely to place importance on retaining a vaginal canal to receive penetration and for gender identity affirmation. These differences in goal prioritization between the 2 groups were most apparent when individuals provided their top 5 goals. In open-ended responses, aesthetics was a major consideration for transgender men, sexual pleasure was a consideration for non-binary individuals, and complications were cited as major concerns by both groups.

CLINICAL IMPLICATIONS

Individual MaPGAS goals should be incorporated into preoperative counseling and may vary by gender identity.

STRENGTHS AND LIMITATIONS

This is the largest study to our knowledge evaluating patient MaPGAS goals and comparing gender identity cohorts. Our results incorporate qualitative open-ended feedback and underscore the importance of understanding patient-specific MaPGAS goals to better facilitate personalized preoperative counseling. Results will be used to guide decision support tool development. Limitations include the cross-sectional study design and reduced socioeconomic diversity.

CONCLUSIONS

While maintaining tactile and erogenous sensation and minimizing surgical complications were universally important goals, significant variations emerged between transgender men and non-binary individuals' MaPGAS goals highlighting the need for personalized preoperative counseling.

Exploring Health Care Professionals' Perspectives on Education, Awareness, and Preferences for Digital Educational Resources to Support Transgender, Nonbinary, and Intersex Care: Interview Study

BACKGROUND

Health care professionals often face challenges in providing affirming and culturally competent care to transgender, nonbinary, and intersex (TNBI) patients due to a lack of understanding and training in TNBI health care. This gap highlights the opportunity for tailored educational resources to enhance health care professionals' interactions with TNBI individuals.

OBJECTIVE

This study aimed to explore health care professionals' perspectives on education and awareness of health issues related to TNBI individuals. Specifically, it aimed to identify their needs, challenges, and preferences in accessing and using digital educational resources to enhance their knowledge and competence in providing inclusive and effective care for this population.

METHODS

A qualitative research approach was used in this study. In total, 15 health care professionals were recruited via convenience sampling to participate in semistructured interviews. Thematic analysis was applied to identify recurring codes and themes.

RESULTS

The study identified several themes and subthemes related to gender diversity awareness, inclusive communication and understanding the needs of TNBI individuals, societal and structural challenges, regulatory gaps in training and support infrastructure, education and training needs for health care professionals on TNBI care, educational resources and training tools for TNBI care, challenges and design considerations for eHealth tools integrations, and evaluating eHealth impact. Participants identified communication barriers, the need for health care providers to use inclusive language, and gaps in both health care system infrastructure and specialized training for gender-affirming care. In addition, participants expressed a need for comprehensive education on transgender and nonbinary health issues, resources for mental health professionals, user-friendly design, and accessibility features in eHealth tools.

CONCLUSIONS

The study revealed substantial deficiencies in health care professionals' knowledge of gender diversity, cultural competency, and the importance of inclusive communication. Addressing the identified barriers and challenges through targeted interventions, such as providing training and support for health care professionals, investing in user-friendly design and data security, and promoting cultural competence in TNBI health care, is essential. Despite integration challenges, eHealth tools have the potential to improve patient-health care professional relationships and access to care.

Representation of Young Non-Binary Characters in Mainstream Fiction

This study characterizes the depiction of young non-binary characters in mainstream fiction. It presents the results of a close-reading analysis of four non-binary characters from different cultural contexts that appeared in Netflix's English-language catalog in November 2023: Cal from Sex Education (UK), Darren from Heartbreak High (Australia), Syd from One Day at a Time (USA), and Yael from Degrassi: Next Class (Canada). The analysis observed aspects of their identity, embodiment, attitude, context, social interactions, and development. The findings reveal patterns that confirm the existence of non-binary stereotypes in the media, as well as divergent features that could be considered manifestations of diversity across Western contexts, thus contributing to a more detailed understanding of the mental models of non-binary individuals that are shared across different cultural contexts.

'I Am they.' Non-Binary Representation in Television Fiction as a Manifestation of Social Conceptions

This qualitative research uses a case study to observe non-binary representation in TV fiction. The Dan character from the Spanish series HIT (RTVE, 2020-present), who is the first openly non-binary character in Spanish TV fiction, is analyzed through the lens of Queer Media Studies. The research applies a combination of content and discourse analysis. Qualitative content categories include a character's visibility, identity, relevance, embodiment, and social interaction. Discourse analysis categories include character's construction, lexicalization, propositional framing, and focus. Results show that Dan's non-binary depiction revolves around three significant axes: dualism, confusion, and exceptional talent. These axes frame social attitudes toward non-binary people and are composed by a set of features identified in Dan's case which also informs society's mind-sets. These traits are proposed as an analytical-theoretical tool for further analyses of non-binary representation in different cultural contexts. The outcomes of this research may inform audiovisual industries, regulations and academia, and are useful to consolidate non-binary media studies.

Gender diverse people's psychological wellbeing and identity in the context of gender affirming speech pathology practice: A qualitative study protocol

BACKGROUND

Gender diverse people may experience discomfort with the sound of their voice. Additionally, their psychological wellbeing, closely connected to a person's identity, or perspective of themselves, is often reduced. A primary goal of gender affirming healthcare is to support clients' psychological wellbeing. Speech pathology practices assist clients to alter their voice to develop authentic self-presentation. These practices have been shown to have positive outcomes related to clients' voices but have not yet been shown to improve overall client psychological wellbeing. Assisting gender diverse people to transform a negative identity perspective into a positive one could have a beneficial impact on their psychological wellbeing. Therefore, to support clients' psychological wellbeing, gender affirming speech pathology care could benefit from focusing on gender diverse clients' identity more broadly, i.e., beyond gender. For this type of care, speech pathologists would need to see themselves as responsible for supporting client psychological wellbeing and identity. However, some clinicians may be hesitant to incorporate more holistic approaches to provide such care. This study aims to explore gender diverse speech pathology clients' views on psychological wellbeing and identity and speech pathologists' perspectives and actions in supporting clients in that regard.

METHODS

This qualitative study approaches the research topic through insights from gender diverse people's and speech pathologists' subjective perspectives and experiences on psychological wellbeing and identity. Gender diverse people will participate in one-on-one episodic interviews, whereas speech pathologists providing gender affirming care will participate in focus group discussions. Data will be analysed with reflexive thematic analysis. The study is supported by collaborators from the gender diverse community. Study findings will be disseminated in an accessible manner to healthcare professionals providing gender affirming care, mainly speech pathologists, and to the gender diverse community.

IMPLICATIONS

Study findings are anticipated to contribute to further understanding gender diverse people's psychological wellbeing and identity in a gender affirming speech pathology context to tailor practices to the unique needs of gender diverse clients.

Key aspects in the development of gender identity and sexual orientation according to trans and gender diverse people: a qualitative approach

For decades, the sexuality of trans and gender diverse people has been researched from a pathologising and medical perspective. This approach makes assumptions about the experiences of trans people, limiting concern for unique and individual experiences, especially for those with non-binary or gender diverse identities. A growing number of articles however are beginning to take the viewpoints of trans people seriously, taking into consideration their unique experiences and insights within the context of sexual and romantic relationships. This study examines the development of gender identity and sexual orientation of a group of trans individuals in Spain. Thirteen self-identified trans participants were interviewed about their sexual orientation, gender identity and the interplay between both those aspects. A constructivist grounded theory methodology was employed to analyse the data. Five major categories were identified: reinterpreting experiences through identification with gender identity and sexual orientation; questioning gender identity and sexual orientation norms; understanding the interplay between gender identity and sexual orientation; developing as a couple; and building a community. Findings highlight the dynamic and relational nature of gender identity and sexual orientation and provide further insight into the interaction of these aspects in the development of trans and gender diverse identities.

Does every transgender person want gender affirming surgery? A survey of transgender individuals in the Midwestern United States

Gender-affirming surgery (GAS) is a highly personalized decision for transgender and gender diverse (TGD) individuals. However, the proportion of TGD individuals who desire GAS is unknown. A questionnaire was created after identifying themes surrounding experiences with gender-affirming medical care by community focus groups. Respondents who reported medically transitioning and who had undergone GAS were compared to those without prior GAS. From 88 completed surveys, 18 (20.5%) individuals did not wish to undergo GAS. Of those medically transitioning and desiring GAS, 15.2% (9/59) desired GAS but had not received it yet, with 6.7% (6/9) identifying as non-binary. Individuals who had not had GAS were more likely to earn under $15,000 annually, compared to $25,000-49,000 in the GAS group (p = 0.01). There was no significant difference in educational level (p = 0.32) or insurance status (p = 0.33). Of TGD individuals who desire GAS, out-of-pocket expenses such as hair removal, opaque insurance policies, lack of social support, and access to gender-affirming providers can hinder the transition process. Understanding barriers and rationales for pursuing GAS can provide targets for improving healthcare delivery to this diverse population.

The Effectiveness of Gender Affirming Voice Training for Transfeminine Clients: A Comparison of Traditional Versus Intensive Delivery Schedules

INTRODUCTION

Gender affirming voice training is a service provided by speech language pathologists to members of the trans and gender diverse community. While there is some evidence to support the effectiveness of this training, the evidence base is limited by a lack of prospective studies with large sample sizes. Finally, there has been only limited research investigating the effectiveness of this training when delivered on intensive (compressed) schedules, even though such schedules are used in clinical practice and may have practical benefits such as increasing service access for this vulnerable population.

METHODOLOGY

This study aimed to investigate and compare the effectiveness gender affirming voice training among 34 trans individuals presumed male at birth aiming to develop a perceptually feminine/female-sounding voice. Among these 34 participants, 17 received their training on a traditional schedule (one 45-minute session per week over 12 weeks) and 17 on an intensive scheduled (three 45-minute sessions per week over 4 weeks). Building on a previous mixed methodological study which indicated that these two training groups were equally satisfied with training outcomes, the current study utilised a wide range of self-report, acoustic, and auditory-perceptual outcome measures (including self-ratings and listener-ratings of voice) to investigate training effectiveness.

DISCUSSION

Results from this study indicated that both training programs were similarly effective, producing positive statistically significant change among participants on a range of outcome measures. Participants in both groups demonstrated significant auditory-perceptual and acoustic voice change and reported increased satisfaction with voice, increased congruence between gender identity and expression, and a reduction in the negative impact of voice concerns on everyday life. However, as has been the case in past studies, training was not sufficient for all participants to achieve their goal of developing a consistently feminine/female-sounding voice.

CONCLUSION

This study provides evidence to suggest that gender affirming voice training for transfeminine clients may be similarly effective whether delivered intensively or traditionally. This study provides evidence to support the practice of using a wide range of outcome measures to gain holistic insight into client progress in gender affirming voice training programs.

Invalidation and Mental Health among Nonbinary Individuals

This study examines the experience of a unique minority stressor, gender identity invalidation (henceforth referred to as invalidation), which is defined as the refusal to accept someone's gender identity as real or valid, among transgender and nonbinary (TNB) individuals. Data are drawn from a large and diverse sample of TNB adults who participated in a quantitative survey concerning transgender identity, minority stress, and mental health (N = 302). Invalidation was assessed using a novel 17-item scale that ascertains the extent to which respondents experienced invalidation across different social contexts. On average, TNB adults in this sample report low levels of invalidation, although a minority experience it at relatively high levels. Experiences of invalidation were significantly higher among nonbinary participants when compared with their binary trans peers. A series of multivariate regression models that control for sociodemographic factors (sex assigned at birth, race/ethnicity, education, age, and income) and well-established indicators of minority stress (felt stigma, enacted stigma) suggest that nonbinary gender identity is independently associated with poor mental health (assessed with the Global Severity Index), and that this association is mediated by invalidation. These findings suggest that invalidation, which is largely unexamined in existing research, merits greater attention as a particularly salient minority stressor influencing mental health among gender diverse populations, nonbinary populations in particular.

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

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.

The association between gender identity fluidity and health outcomes in transgender and gender diverse people in New Orleans and Los Angeles, USA

Objectives

Most studies with transgender and gender diverse people (TGD) examine gender identity cross-sectionally. Gender identity and expression can fluctuate over time, which may have implications for health. The goal of our study was to compare mental health, substance use and healthcare utilization among 163 gender identity fluid (1 + identity change) and gender identity consistent (no change) TGD.

Methods

Participants were recruited in New Orleans, LA and Los Angeles, CA and assessed at four-month intervals over 24 months between 2017 and 2021. We conducted logistic regression models to test for associations between gender identity fluidity and health outcomes at 24 months. In post hoc analyses, we explore how controlling for cross-sectional report of gender identity at 24 months may impact the association between gender identity fluidity and health outcomes.

Results

We saw no significant differences across mental health and substance use indicators. Gender identity fluid participants had 5.9 times the adjusted odds (95 % Confidence Interval (CI): 1.9-18.4) of no recent healthcare visit compared to gender identity consistent participants. After controlling for cross-sectional report of gender identity, the association between gender identity fluidity and no recent healthcare visit remained significant (aOR = 4.6; 95 % CI: 1.4-14.8).

Conclusions

Because providers have limited experience providing gender-affirming care or treating patients with fluid gender identities, gender identity fluid patients may avoid healthcare more than gender identity consistent patients. Our preliminary study highlights the need to measure gender identity longitudinally and examine the relationship between gender identity fluidity and health.

Describing Non-Binary People's Encounters with the Healthcare System: A Qualitative Study in Catalonia (Spain)

Non-binary people face numerous stressors in their daily lives, including personal, interpersonal, and environmental. These stressors gain strength when such individuals access healthcare services, and discrimination and cisgenderism become the main barrier to obtaining gender-affirming healthcare. This study aimed to describe the experiences of non-binary people regarding the care and medical attention received in Catalonia (Spain). A qualitative phenomenological study was conducted with 21 non-binary people recruited using snowball sampling in 2022. Data were gathered through open-ended interviews and analyzed using thematic analysis. Two main themes were identified, which were further classified into two categories each: Theme 1-This is me composed of the categories, "My Name and My Pronouns" and "One's Chosen Gender," and Theme 2-I do not exist for the health system consisting of "Uneducated Health System in Sexual Health" and "Feeling Like an Outsider for Being Non-Binary." Non-binary people face multiple stressors when accessing the healthcare services that makes them feel invisible, vulnerable, and marginalized. Further widespread implementation of person-centered care is essential to promote the relationship between non-binary people and the healthcare system. In addition, further sexual health training is required for all health professionals.

Systematic Review on Gender-Affirming Testosterone Therapy and the Risk of Breast Cancer: A Challenge for Physicians Treating Patients from Transgender and Gender-Diverse Populations

Conflicting evidence exists about the risk of breast cancer in transgender and gender-diverse (TGD) patients treated with testosterone. This review aimed to summarize current knowledge regarding the risk of breast cancer associated with gender-affirming testosterone treatment (GATT). A systematic literature search using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist was conducted in January 2023 through Ovid, Scopus, and Web of Science databases. English-language, peer-reviewed articles evaluating breast cancer in TGD patients after GATT that met the inclusion criteria were included. This review included 22 articles, with 14 case reports, 4 case series, and 4 retrospective cohort studies. The review identified 26 TGD patients who developed breast cancer post-GATT therapy, with inconclusive evidence on the relationship between testosterone and the risk of breast cancer in TGD patients. This uncertainty in part arises from the mechanisms governing testosterone's effects within breast tissue, with contrasting theories proposing both proliferative and antiproliferative impacts. Considering this ambiguity, it is imperative for healthcare providers to engage in informed discussions with patients prior to initiating hormone therapy to discuss potential adverse effects, including the possibility of breast cancer development in TGD individuals. Patient education and shared decision-making are essential components of responsible care in this context.

Body Image Among Sexual and Gender Minorities: An Intersectional Analysis

Body image is consequential for overall well-being and has a complex relation to gender. Sexual and gender minority (SGM) individuals develop body image amid intersecting systems of oppression, such as sexism, cisnormativity, heteronormativity, and gender binary pressures. This study used an intersectionality framework to examine how various aspects of gender identification (cis/trans, binary/nonbinary, woman/man identification) related to body image differences among SGM individuals. We also assessed whether identification with conventionally masculine and feminine personality traits predicted body image. We used one-way and two-way ANOVAs and linear regressions to analyze two indicators of body image (body appreciation and drive for muscularity) in a sample of 643 SGM individuals (148 sexual minority (SM) cis women, 171 trans women, 121 SM cis men, 43 trans men, 160 nonbinary individuals). Results implicated cisnormativity as an influential and hierarchical force for body image, although woman/man and binary/nonbinary identification also played roles in group differences. With a few exceptions, masculine but not feminine trait identification significantly predicted body appreciation and drive for muscularity, indicating a complicated association with overall body image. These findings underscore the value of an intersectional lens for analyzing how broad social forces may manifest in individual-level body image for SGM individuals.

"The third table where I would sit comfortably": narratives of nonbinary identity routes

Background

Research on nonbinary people has been growing steadily. However, most studies have focused on gender identity development in binary cisgender or transgender populations, and there is a lack of knowledge about the experiences and milestones of nonbinary identification, including the many challenges of living in a binary world. In Italy, nonbinary individuals are exposed to various forms of discrimination and face multiple forms of invisibility-linguistic, social, and legal.

Aim

The present study aimed to explore the complex experiences of Italian individuals who do not identify with either of the binary gender categories, shedding light on the processes of awareness of their nonbinary identity.

Methods

Twenty nonbinary participants, aged 19 to 36 years, were administered a semi-structured interview that was explicitly created for this study. The Consensual Qualitative Research methodology was applied to the transcripts of the interviews.

Results

The research delineated four domains: growing up in a binary world, referring to retrospective descriptions of gender normativity and lack of models; gender dysphoria, referring to descriptions related to body and social gender dysphoria; nonbinary awareness, referring to the influence of sexual and romantic relationships, friendships and aggregative spaces, as well as social media, traditional media and literary works-all contributing to the process of personal identity synthesis; and looking forward, referring to the tension of imagining an identity that is constantly evolving (i.e. fantasies and desires of medical and gender-affirming interventions, negative expectations regarding the future, and self-realization).

Conclusion

In societies with a binary understanding of gender, nonbinary individuals face complex challenges and must use multiple strategies to negotiate and express their identities. A deeper understanding of the processes of awareness of gender identity in this population may help to improve clinical practice with gender minoritized individuals.

Fostering Gender-IQ: Barriers and Enablers to Gender-affirming Behavior Amongst an Australian General Practitioner Cohort

While the visible population of trans and gender diverse Australians has grown significantly in recent years, primary health-care access remains hindered by a lack of practitioner competency and stigmatization. This article draws on qualitative research of purposively selected gender-affirming general practitioners (GPs) in Australia to explore barriers, and enablers when treating trans and gender diverse patients. Perspectives and behaviors during the gender-affirming clinical encounter were theoretically informed through minority stress theory, and master narrative frameworks. Reflexive thematic analysis facilitated a rich description of exemplary gender-affirming primary care. A considerable gap exists between structural, clinical, and cultural behaviors among competent gender-affirming GPs in Australia, and the majority of practitioners evidenced in the literature. This critical analysis contributes to better understanding how gender-affirming Australian GPs diffuse minority stress, negotiate cis-normative biases, and foster a person-centered longitudinal therapeutic relationship with their trans and gender diverse patients. An encounter the article argues may also provide an essential buffer for GPs in Australia against the risk of professional burnout. Gender-affirming practice should be taught as a core competency and be required as professional development for GPs in Australia, to ensure a beneficial clinical encounter for the growing trans and gender diverse population.

Misgendering and the health and wellbeing of nonbinary people in Canada

Background: Misgendering-using the wrong name, pronoun, or gendered language to refer to someone-is known to have negative impacts on the mental health and well-being of trans individuals generally. However, little is known about the effects of misgendering on nonbinary people specifically. Aims: As such, our research asked: 1) Among nonbinary people, what factors are associated with frequency of misgendering?; and 2) Do nonbinary people who experience misgendering less often have better health outcomes? Methods and Results: We analyzed data from Trans PULSE Canada, a community-based survey of trans and nonbinary people living in Canada, using a subset (n = 1091) who identified as nonbinary and completed questions on misgendering. Misgendering was a frequent and distressing experience for nonbinary participants, with 59% misgendered daily, 30% weekly or monthly, and only 11% yearly or less. Most (58%) reported being very or quite upset when misgendered. About one in eight (13%) corrected others most or all of the times they were misgendered. Daily misgendering was more common among nonbinary people who were younger than 25 years old (64%, p < .0001), visibly disabled (74%, p = .003), assigned female at birth (61%, p <.0001) or racialized as a person of color and assigned male at birth (65%, p < .0001) compared with their counterparts. In multivariable regression analyses, less frequent misgendering (weekly/monthly vs. daily) was associated with a lower OASIS anxiety score (β = -0.555, 95% CI = -1.062, -0.048). Discussion: Our research highlights the complexity of outness, passing, concealment, and affirmation for nonbinary people living at the intersections of marginalizations. Future research could build stronger causal analyses of the impacts of misgendering, how nonbinary people cope with misgendering, and policy and interventions to decrease misgendering.

"It's like a happy little affirmation circle": a grounded theory study of nonbinary peoples' internal processes for navigating binary gender norms

Background: Nonbinary people experience marginalization through discrimination, rejection, microaggressions, and stigma as a result of not always conforming to societal gender norms embedded in the gender binary. There is limited research about how nonbinary Black, Indigenous, and People of Color (BIPOC) living in the United States navigate societally enforced binary gender norms, which is especially important to understand given how racism and Euro-colonization have enforced the gender binary. Better understanding the internal strategies nonbinary people use to cope, embody affirmation, and regulate emotions in response to marginalizing experiences could increase understanding of how to best prevent and address the health disparities experienced by nonbinary people. Aim: Drawing on the practices of interrogating norms central to queer theory with a sensitization to racism and settler colonialism, this study aimed to identify a framework to understand nonbinary peoples' processes of navigating gender norms internally through their lived experiences with an awareness of how context impacts these processes. Method: This qualitative interview study utilized construcitivist grounded theory methodology, guided by queer theory. Twenty-one nonbinary individuals were interviewed over Zoom with 15 being BIPOC. Results: Participants navigated binary gender norms internally by self-defining affirmative nonbinary ways of being, noticing affirmation in a chosen community that allowed them to experience existing authentically outside of binary gender norms, and internally connecting to an embodied, authentic sense of gender within themselves and in community with other nonbinary people. These internal processes were influenced by two contextual factors: societal and cultural expectations of gender; and the contextual impacts of holding multiple marginalized identities. Discussion: Understanding the contexts of the gender binary, racism, and cissexism that impact nonbinary people on a daily basis is crucial for mental health professionals, researchers, policy makers, and creators of gender inclusive education and support programs to support and affirm nonbinary people.

Identity Development and Self-Esteem in Transgender Men: The Importance of Masculinity

Because transgender people often suffer from concerns such as increased depression and anxiety, promoting positive and healthy mental well-being within this community is valuable. Two aspects of well-being that may be particularly relevant to the trans community are identity development and self-esteem. We hypothesized that a better overall transition experience (access to medical and psychological care, support from friends and family, etc.) would predict better identity development, individual self-esteem, and collective self-esteem in transgender men. This prediction was supported in a sample of 145 transmen from 15 different countries. Further exploratory analyses reveal that the direct effects of the transition process on identity development and individual self-esteem were significantly mediated by participants' perceived masculinity-but this mediation did not apply to collective self-esteem. We also found that when comparing overall transition experiences in the countries represented in our sample, the process was most positive in transmen from Australia and New Zealand, with experiences in the U.S., Canada, and Europe as less positive. Providing a supportive transition process and validating transmen's masculinity are important factors in paving the way for them to have healthy identity development and self-esteem.

Neoliberalism, Control of Trans and Gender Diverse Bodies and Social Work

PURPOSE

This paper explores how neoliberal ideologies inform both social and political agendas that influence how social workers can provide support to trans and gender diverse people attempting to access gender-affirming healthcare, using an analysis of social workers' experiences working in mental health in Nova Scotia, Canada.

METHOD

Qualitative semi-structured interviews provide a perspective of the experiences of social workers in Nova Scotia and how their ability to provide mental health services to trans and gender diverse people is impacted by neoliberalism.

RESULTS

Most social workers attributed the structural context of working within a bio-medical system as contributing to social workers being disempowered, undermined, and not able to practice according to the values of their profession thus limiting their ability to provide affirming mental health supports to trans and gender diverse people in ways that align with their social work professional ethics and values.

DISCUSSION

Through examining how neoliberal ideologies create notions of ideal social citizens by controlling the body, the paper explores how lived experience of neoliberal practices in mental health social work reinforce transnormativity. This paper highlights the necessity for social workers to resist dominant neoliberal and medicalized discourses which serve as mechanisms of power and control.

CONCLUSION

The paper concludes with recommendations for social work practice with trans and gender diverse populations.

Authentic gender development in non-binary children

At present, the conceptualization of gender as a spectrum as well as non-binary identities have become increasingly visible and embraced. We are using non-binary as an umbrella term that refers to individuals who self-identify as a gender outside the gender binary, and/or who do not identify as always and completely being just a man or a woman. Our goal is to begin to create a framework for understanding gender development in non-binary children ages 0 to 8, since previous models have operated on cissupremacist assumptions, not applicable to non-binary people. As there is virtually no empirical data on the subject, we conducted a thorough literature review of current gender development theories and used our positionality as non-binary researchers to postulate two minimum criteria for non-binary gender identification: that a child learns about the existence of non-binary identities, and that they do not identify with the definitions they have been taught of what a boy or girl is. Children can learn about non-binary identities through media and knowledgeable community members and can develop "gender traits" authentically and come to identify as non-binary through biological predispositions, parental support, modeling, and being in peer groups that are supportive of identity exploration. Yet, children are not simply a product of their nature and nurture, as evidence has shown that humans are active agents in their gender development from a young age.

The struggle with transnormativity: Non-binary identity work, embodiment desires, and experience with gender dysphoria

I examine how non-binary people who have considered, or accessed, gender-affirming health care experience accountability to transnormativity using 12 in-depth interviews conducted between 2018 and 2019 in a midwestern American city. I detail how non-binary people who want to embody genders that are still largely culturally unintelligible think about identity, embodiment, and gender dysphoria. Using grounded theory methodology, I find that non-binary identity work around medicalization differs from that of transgender men and women in three primary ways: 1) regarding how they understand and operationalize gender dysphoria, 2) in relation to their embodiment goals, and 3) concerning how they experience pressure to medically transition. Non-binary people describe increased ontological uncertainty about their gender identities when researching gender dysphoria that is contextualized by an internalized sense of accountability to the transnormative expectation for medicalization. They additionally anticipate a potential medicalization paradox, where accessing gender-affirming care leads to a different type of binary misgendering and risks making their gender identities less, rather than more, culturally intelligible to others. Non-binary people also experience external accountability to transnormativity as pressure from trans and medical communities to think about dysphoria as inherently binaristic, embodied, and medically treatable. These findings indicate that non-binary people experience accountability to transnormativity differently than trans men and women. Since non-binary people and their body projects often disrupt the transnormative tropes that are the framework for trans medicine, they find trans therapeutics, and the diagnostic experience of gender dysphoria, uniquely problematic. Non-binary experiences of accountability to transnormativity indicate the need to re-center trans medicine to better accommodate non-normative embodiment desires and focus future diagnostic revisions of gender dysphoria to emphasize the social aspects of trans and non-binary experience.

The Price to Pay for Being Yourself: Experiences of Microaggressions among Non-Binary and Genderqueer (NBGQ) Youth

This study explores the experiences of NBGQ youth with microaggressions. It investigates the types of microaggressions they face and their subsequent needs and coping mechanisms and the impacts on their lives. Semi-structured interviews with ten NBGQ youth in Belgium were conducted and analyzed using a thematic approach. The results showed that experiences of microaggressions were centered around denial. The most common ways to cope were finding acceptance from (queer) friends and therapists, engaging in a conversation with the aggressor, and rationalizing and empathizing with the aggressor, leading to self-blame and normalization of the experiences. Microaggressions were experienced as exhausting, which influenced the extent to which the NBGQ individuals wanted to explain themselves to others. Furthermore, the study shows an interaction between microaggressions and gender expression, in which gender expression is seen as a motive for microaggressions and microaggressions have an impact on the gender expression of NBGQ youth.

The double-edged sword of PCOS and gender: exploring gender-diverse experiences of polycystic ovary syndrome

Background: Past research on polycystic ovary syndrome (PCOS), a chronic endocrine condition, has focused on the experiences of cisgender women. Aims: The purpose of the present study was to address the knowledge gap about gender-diverse individuals by exploring their lived experiences with PCOS and to better understand if and how their gender identity affected their experience of PCOS. Methods: To explore this, we recruited nine non-binary people and one transgender man with a PCOS diagnosis for qualitative interviews. Results: Three overarching themes emerged: PCOS as a burden, PCOS as an occasion, and PCOS as a benefit. While some aspects of PCOS created an additional burden for our participants, other symptoms such as excess body and facial hair could be empowering and affirming, revealing a positive aspect of this chronic condition. Conclusion: This study is the first to describe the lived experiences of gender-diverse individuals with PCOS, uncovering burdens as well as some benefits. Future research in this population may reveal not only the particulars of what PCOS is like for them but also more generalizable insights into the highly gendered perception and treatment of PCOS.

Speech beyond the binary: Some acoustic-phonetic and auditory-perceptual characteristics of non-binary speakers

Speech acoustics research typically assumes speakers are men or women with speech characteristics associated with these two gender categories. Less work has assessed acoustic-phonetic characteristics of non-binary speakers. This study examined acoustic-phonetic features across adult cisgender (15 men and 15 women) and subgroups of transgender (15 non-binary, 7 transgender men, and 7 transgender women) speakers and relations among these features and perceptual ratings of gender identity and masculinity/femininity. Differing acoustic-phonetic features were predictive of confidence in speaker gender and masculinity/femininity across cisgender and transgender speakers. Non-binary speakers were perceptually rated within an intermediate range of cisgender women and all other groups.

The Experiences of Trans and Gender Diverse Clients in an Intensive Voice Training Program: A Mixed-Methodological Study

Intensive schedules in behavioral voice therapy and training have been proposed to have a range of positive benefits including enhanced outcomes, high client and clinician satisfaction, and reduced client attrition. In the sub-field of behavioral voice training for trans and gender diverse clients, intensive schedules may also present a means of increasing service access opportunities for a vulnerable population. Despite the proposed benefits there has been limited research investigating client experiences in intensive voice training programs. The current study utilized a mixed-methodological approach to compare participant experiences in an intensively scheduled (three 45-minute sessions per week, over 4 weeks) versus a traditionally scheduled (one 45-minute session per week, over 12 weeks) voice training program for trans and gender diverse participants aiming to develop a perceptually feminine-sounding voice. Participant experiences were compared using a satisfaction questionnaire delivered to both training groups as well as thematic analysis of semi-structured interviews conducted with participants in the intensive group. Results suggested that individuals in the intensive training program had both positive and negative experiences related to the intensive schedule, but all viewed the program favorably and expressed a preference for intensive training based on their experiences. However, it was also found that overall satisfaction and attrition did not differ significantly between the intensive and traditional training groups and that many factors contributing to participant satisfaction in the intensive program were unrelated to the intensive schedule. Results from the current study also suggest that experiences in intensive programs may be highly variable and mediated by factors such as clients' individual personalities and preferences. The current study concludes that intensive schedules present a viable alternative to traditional schedules in practice, with additional considerations and directions for future research also discussed.

Results from an LGBTQ+ Community Health Needs Assessment in Nassau and Suffolk Counties of New York State

LGBTQ+ individuals experience health care disparities and difficulty accessing affirming care. Little is known regarding the health and experiences among subpopulations of specific sexual orientations and gender identities (SOGI). We implemented the first LGBTQ + health needs assessment survey in Nassau and Suffolk Counties, New York, to assess individuals' health care experiences, behaviors, access to care, and health care needs. The sample (N = 1150) consisted of many SOGI subgroups. Greater than 60% of respondents reported symptoms of chronic depression; over one third reported disrespectful health care experiences; and two thirds experienced verbal harassment. Bisexual/bicurious, pansexual, queer, gender nonconforming and transgender individuals experienced highest rates of mental health concerns and difficulty accessing care. Behavioral health concerns were also high among Black, multiracial, Hispanic, Asian, young adult, and lower-income respondents. Gaining an understanding of unique differences among LGBTQ+ subgroups can guide implementation of services targeting specific subpopulations to improve access to care and reduce disparities.

Implementation of a Risk Reduction Protocol in Youth Violence Research

This article presents data from the Growing up with Media study related to the implementation of a risk reduction protocol that resulted in three groups of youth: low-risk youth (no flags), youth flagged because of violence involvement and not clinically referred; and flagged youth who were referred to a team clinician due to additional risk considerations. Data is from 3,979 U.S. youth 14-15 years of age recruited through social media between October 2018-August 2019. Four in ten youth were flagged for review. Findings suggest that this methodology of identifying and reviewing cases appears to be working as intended: Not only did referred youth have more flags than non-referred youth, but post-hoc analyses suggested that these youth also had higher rates of psychosocial problems (e.g., non-victimization adversity, substance use and depressed mood). The implementation of a risk reduction protocol such as the one described in this article adds a layer of human subject protection beyond the more standard list of websites and hotlines provided to all participants in most studies. This protocol leads the way for future studies to recreate a similar process to address concerning responses collected from survey research.

Non-binary gender/sex identities

An increasing number of individuals openly identify as non-binary (i.e., not exclusively female or male). Accordingly, psychological research on non-binary identities has expanded rapidly. We review key insights from this growing literature, first examining work that has demonstrated links between beliefs about the true nature of gender and/or sex (gender/sex) and feelings toward non-binary people. We also review research on non-binary people's self-concepts, which has shown the inadequacy of binary-focused gender/sex measurement practices for effectively studying non-binary people's lives and has suggested treating gender/sex as multidimensional. Then, we consider scholarship on non-binary people's wellbeing, including work exploring sources of joy and pleasure in non-binary people's lives (e.g., gender euphoria). Finally, we discuss recent advances in gender-inclusive theories and methods.

Body image and treatment desires at clinical entry in non-binary and genderqueer adults

Background: Gender clinics are experiencing an increase in non-binary and/or genderqueer (NBGQ) individuals applying for gender affirming medical treatment (GAMT). GAMT is a well-established approach in reducing body dissatisfaction in binary transgender (BT) people, but knowledge on GAMT in NBGQ people is limited. Previous research shows that NBGQ individuals report different treatment needs compared to BT individuals. In attempting to address this difference, the current study examines the association between identifying as NBGQ, body dissatisfaction and their underlying motives for GAMT. The main research objectives were to describe the desires and motives for GAMT in NBGQ people and to examine how body dissatisfaction and gender identity relate to one's request for GAMT. Methods: Online self-report questionnaires were administered on 850 adults referred to a gender identity clinic (Mdn age = 23.9 years). Gender identity and desires for GAMT were surveyed at clinical entry. Body satisfaction was assessed with the Body Image Scale (BIS). Multiple linear regressions were used to examine whether BIS scores differed between NBGQ and BT individuals. Chi-square post hoc analyses were used to identify differences in treatment desires and motives between BT and NBGQ individuals. Logistic regressions were conducted to study the association between body image, gender identity and treatment desire. Results: Compared to BT persons (n = 729), NBGQ persons (n = 121) reported less body dissatisfaction, primarily with the genital area. NBGQ persons also preferred fewer GAMT interventions. If a procedure was not desired, NBGQ individuals more often motivated this on the basis of their gender identity, while BT individuals more often cited the risks of the procedure as their primary reason. The study confirms the need for more NBGQ specialized care, as they have a distinct experience of their gender incongruence, physical distress and express specific needs in GAMT.

Experiences of Transgender Identity in a Sample of Primarily White Binary Trans Masculine and Nonbinary Individuals

Purpose

This study investigated the differences between binary and nonbinary transgender individuals' experiences of transgender identity through the Transgender Identity Survey (TIS).

Method

Binary and nonbinary participants in the United States were recruited through social media. Despite efforts to recruit binary trans feminine individuals and People of Color, the participants in this study were primarily White binary trans masculine and nonbinary individuals. Participants completed the TIS and demographic questions online.

Results

Four independent t-tests were conducted along the TIS subscales of passing, shame, alienation, and pride. We grouped our sample as "binary" and "nonbinary" based on participant-reported gender. After controlling for multiple comparisons, we had four main findings. First, nonbinary individuals possessed significantly less concern about passing (or being perceived) as their affirmed gender than binary individuals. Second, nonbinary individuals possessed significantly less shame than their binary counterparts. Third, we found no significant differences between binary and nonbinary participants with regard to their feelings of alienation from other transgender individuals. Fourth, nonbinary individuals possessed significantly more pride in their transgender status than binary individuals.

Conclusion

Our findings, which should be interpreted in light of our sample (i.e., predominantly White binary trans masculine and nonbinary people), suggest that the current standard of care (medical transition) for transgender individuals may not account for the needs of the nonbinary community. Furthermore, concepts of passing and shame may be more nuanced for nonbinary people and warrant future research. Transgender individuals experiencing distress associated with their transgender status may benefit from psychological care aimed at building community resources.

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.

Deaf Identity Salience: Tracing Daphne’s Deaf Identity Salience Through Switched at Birth

Mainstream television scarcely features Deaf persons. When they do, they are usually cameo, secondary, and rarely multidimensional characters. This paper examines Deaf identity of a main character, Daphne Vasquez, on the popular show Switched at Birth. We analyze moments where Daphne’s identity, a constructed Deaf identity, is showcased. We map how her identity is salient across seasons and then examine key moments of identity formation as Daphne negotiates her Deafness. We find a strong display of Deaf identity salience and impactful moments in the show that resulted in more positive, holistic representations of Deafness. In recent years, the media has come under increased scrutiny for limited representations of minority identities; this case study seeks to contribute to that conversation by studying a show explicitly focused on increased representation. This work is important as it not only examines a show which successfully features a character with a traditionally stigmatized identity but simultaneously quantifies how that identity is invoked as a message to viewers. This paper bridges cultural sociology with social psychology to gain a deeper understanding of the importance of identity representation in entertainment media and comments directly on the social impact of Daphne’s character on Deaf presence in 21st century media.

TRANSALUD: A qualitative study of the healthcare experiences of transgender people in Barcelona (Spain)

Transgender identities are still considered a psychiatric pathology in many countries according to the prevailing biomedical model. However, in recent years, this pathologizing vision has begun to shift towards a perspective that focuses on the diversity of transgender peoples' experiences. However, some transgender people still face denial of services, discrimination, harassment, and even violence by healthcare professionals, causing them to avoid seeking ongoing or preventive healthcare. This article describes the health experiences of transgender people in Barcelona regarding their access and use of non-specialized health services. Semi-structured interviews were conducted using a descriptive phenomenological approach with sixteen transgender people between December 2018 and July 2019. The data were analyzed descriptively and thematically following the method proposed by Colaizzi with the help of the Atlas.ti8 software. Transgender people care experiences were divided into three categories: overcoming obstacles, training queries, and coping strategies. Participants identified negative experiences and difficulties with the health system due to healthcare providers' lack of competence. Discriminatory, authoritarian, and paternalist behaviors are still present and hinder the therapeutic relationship, care, and access to healthcare services. There is a fundamental need for the depathologization of transgender reality and training for healthcare professionals in the field of sexual diversity. Training in sexual and gender diversity must be included in the curricula of university courses in the health sciences.

Bridging the Gap Between Practice Guidelines and the Therapy Room: Community-Derived Practice Adaptations for Psychological Services with Transgender and Gender Diverse Adults in the Central United States

Individuals who identify as transgender or gender diverse (TGD) are presenting at mental health clinicians' offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems for which a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGD people. However, what is needed are community informed recommendations to bridge from the official guidelines to clinicians' in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist's self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.

A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria

INTRODUCTION

Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria.

METHODS

In-depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services.

RESULTS AND DISCUSSION

Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender-inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender-inclusive and gender-affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender-inclusive CSO clinics.

CONCLUSIONS

This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender-inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender-affirming HIV services.

To Go or Not to Go: Factors That Influence Health Care Use Among Trans Adults in a Non-Representative U.S. Sample

Trans people tend to utilize health care at rates lower than cisgender people, which commonly results in short-term and long-term unfavorable health outcomes. Theoretically informed by Andersen's behavioral model of health services use and Lerner and Robles' adapted behavioral model of health services use for transgender people, the current study examined how individual characteristics of trans people along with the external environment and health care service environment they must navigate impact their health care utilization. Binary logistic regression was used to analyze data from the 2015 United States Trans Survey (N = 27,715), the largest trans sample to date. Perception of health care provider (HCP) knowledge, health insurance status, and health care costs each produced the strongest effect on visiting a doctor or HCP in the past year. The results showed that having a provider that had some level of knowledge about trans people was potentially most critical to increase utilization. Discussion points include increasing trans-focused curriculum in health professional schools, utilizing trans standardized patients in health professional schools, and holding insurance companies accountable to provide trans affirming care.

Sexual Self-Concept Discrepancies Mediate the Relation between Gender Dysphoria Sexual Esteem and Sexual Attitudes in Binary Transgender Individuals

Sexual responding in transgender people has typically been investigated from a medical and functional perspective. Aligning with the biopsychosocial model, it is however equally important to consider psychological aspects of sexuality in this population. We propose that the Sexual Self-Concept (SSC) theory offers a valuable framework to understand (sexual) wellbeing in transgender people, while Self-Concept Discrepancy (SCD) theory could offer an explanation of the mechanisms underlying negative SSCs related to gender dysphoria. We investigated differences in SSC (consisting of sexual esteem, sexual attitudes, and sexual self-efficacy) in 197 binary transgender and 205 cisgender individuals using an online survey and explored the mediating role of actual/ideal self-discrepancies in explaining the relation between gender dysphoria and SSC. Transgender and cisgender individuals differed significantly in seven out of eight components related to sexual esteem and sexual attitudes. Actual/ideal self-discrepancies mediated the relationship between gender dysphoria and the SSC in transgender individuals for the sexual esteem components related to body perception, conduct, and attractiveness, as well as for sexual anxiety. We found no relation between gender dysphoria and the other SSC components in this group. We conclude that SSC discrepancies could be a valuable treatment target to improve transgender individuals' sexual esteem and sexual attitudes.

Development of the nonbinary gender microaggressions (NBGM) scale

Background: While research pertaining to nonbinary microaggressions has become increasingly comprehensive in recent years, a measure specifically assessing this construct does not yet exist.Aims: The purpose of the present research was to develop and validate the Nonbinary Gender Microaggressions (NBGM) scale, which will allow future researchers to quantitatively examine nonbinary individuals' experiences of microaggressions. Methods and Results: In Study 1 (n = 5), interviews with nonbinary individuals were conducted to explore their microaggressive experiences. The results of this study, as well as findings from previous qualitative research, were used to generate an initial pool of 92 items. In Study 2 (n = 158), a principal component analysis, which was used for item reduction, resulted in the retention of 41 items. In Studies 3 (n = 151) and 4 (n = 266), an exploratory factor analysis yielded a 23-item 5-factor solution (i.e., Negation of Identity [6 items], Inauthenticity [6 items], Deadnaming [4 items], Trans Exclusion [3 items], and Misuse of Gendered Terminology [4 items]), and a confirmatory factor analysis found that this solution demonstrates adequate model fit. Evidence of the measure's scale score reliability, convergent validity, and incremental validity also were provided. Discussion: These findings indicate that, overall, the NBGM scale is a psychometrically sound measure of nonbinary individuals' experiences of microaggressions. As such, this measure can be utilized by future researchers and clinicians to better understand nonbinary individuals' microaggressive experiences.

Perceived gender and client satisfaction in transgender voice work: comparing self and listener rating scales across a training program

BACKGROUND/AIM

Scales used to collect perceptual ratings related to a speaker's gender are widely used in gender affirming voice training for trans individuals. Such scales may be used as outcome measures to gain insight into whether training has helped clients meet personal goals related to gender expression. These scales are also widely used in general research investigating the relationship between vocal characteristics and perceptions of speaker gender. However, past studies in these areas have varied in the terminology used to label rating scales and the impact of this variation is currently unknown. Additionally, research has not yet fully explored the relationship between self- and listener-ratings of trans participant voices and trans participant satisfaction with voice, and whether or not these relationships change after trans participants undertake gender affirming voice training. This research paper aimed to explore these relationships and address these research gaps.

METHODS

A group of 34 trans participants were asked to rate their voices before and after participating in gender affirming voice training. Trans participant voice samples from before and after training were also presented to a group of 25 listeners for rating. Perceptual ratings were made on two Visual Analogue Scales (VAS) with anchors 'very feminine/very masculine' and 'very female/very male'. Trans participants also rated their satisfaction with their current voice on a VAS with anchors 'very satisfied/very unsatisfied'. Correlation coefficients were calculated to investigate the relationship between collected ratings.

RESULTS

Differences in scale labels were found to have minimal impact on ratings made by both trans participants and listeners. Trans participant self-ratings were found to correlate with listener ratings, but this correlation was not strong Trans participant self-ratings had a consistently stronger relationship with their self-rated vocal satisfaction. The study contributed new findings that these differences may be more pronounced after trans participants have completed voice training.

DISCUSSION/CONCLUSION

This study suggests that results from past studies that have used differently labelled scales to collect ratings related to gender perception based on voice are suitable to compare. This study also discusses the implications reported differences between trans participant self-ratings and listener ratings may have for research and clinical practice.

Mental and sexual well-being in non-binary and genderqueer individuals

Background

Non-binary and genderqueer (NBGQ) individuals do not identify with a binary gender identity. Some but not all NBGQ individuals identify as transgender, and it is currently unclear on which aspects of mental and sexual well-being NBGQ and binary transgender individuals may differ.

Aim

To compare NBGQ, binary transgender and cisgender individuals on variables related to mental well-being, sexual well-being, and sexual self-concept discrepancies.

Methods

We conducted an online questionnaire study in 125 transgender men, 72 transgender women, 78 NBGQ individuals, 98 cisgender men, and 107 cisgender women.

Results

For most variables, NBGQ individuals did not differ from binary transgender individuals. These two groups differed only on gender dysphoria and transgender specific body image worries, which were both lower in the NBGQ group. Compared to the cisgender group, NBGQ individuals scored higher on gender dysphoria, actual/ought sexual self-concept discrepancies, and actual/ideal sexual self-concept discrepancies, and lower on general life satisfaction and sexual esteem related to body perception.

Discussion

These results offer a first quantitative analysis of sexual well-being in NBGQ individuals, and highlight that - while both groups face unique challenges - NBGQ individuals encounter similar difficulties concerning mental and sexual well-being as binary transgender individuals.

Gender Identity Milestones, Minority Stress and Mental Health in Three Generational Cohorts of Italian Binary and Nonbinary Transgender People

Transgender and gender nonconforming (TGNC) people experience high rates of minority stress and associated risk for negative health outcomes. However, during the last years, significant positive socio-cultural changes have happened, and younger cohorts of TGNC individuals are having diverse experiences compared to older cohorts. By integrating the minority stress theory and the life course perspective, this cross-sectional, web-based study aimed to explore in 197 Italian TGNC people aged 18 to 54 years (M = 29.82, SD = 9.64) whether the average ages of gender identity milestones (i.e., first insights about being TGNC, self-labeling as a TGNC person, and coming out), minority stress, and mental health vary among three generational cohorts (i.e., Generation Z, Millennials, and Generation X). Compared with older cohorts, younger participants: (a) were more likely to be in the trans-masculine spectrum; (b) self-labeled as TGNC and came out earlier; (c) had more negative expectations and lower levels of disclosure; and (d) had higher levels of mental health problems. No generational differences related to first insights about being TGNC and distal minority stressors were found. Furthermore, compared with binary individuals, participants with a non-binary identity: (a) reported later ages for the gender identity milestones; (b) had higher negative expectations; and (c) had higher levels of mental health problems. Overall, our findings indicated that changes in the social environments have a limited impact on stigmatization processes and mental health of Italian TGNC people.

Social conditions and mental health during COVID-19 lockdown among people who do not identify with the man/woman binomial in Spain

Evidence suggests that non-binary people have poorer mental and physical health outcomes, compared with people who identify within the gender binomial (man/woman). Research on the impact of the COVID-19 pandemic on mental health has been conducted worldwide in the last few months. It has however overlooked gender diversity. The aim of our study was to explore social and health-related factors associated with mental health (anxiety and depression) among people who do not identify with the man/woman binomial during COVID-19 lockdown in Spain. A cross-sectional study with online survey, aimed at the population residing in Spain during lockdown, was conducted. Data were collected between the 8th of April until the 28th of May 2020, the time period when lockdown was implemented in Spain. Mental health was measured using the Generalised Anxiety Disorder 7-item (GAD-7) scale for anxiety, and the Patient Health Questionnaire (PHQ-9) for depression. The survey included the question: Which sex do you identify with? The options "Man", "Woman", "Non-binary" and "I do not identify" were given. People who answered one of the last two options were selected for this study. Multivariate regression logistic models were constructed to evaluate the associations between sociodemographic, social and health-related factors, anxiety and depression. Out of the 7125 people who participated in the survey, 72 (1%) identified as non-binary or to not identify with another category. People who do not identify with the man/woman binomial (non-binary/I do not identify) presented high proportions of anxiety (41.7%) and depression (30.6%). Poorer mental health was associated with social-employment variables (e.g., not working before the pandemic) and health-related variables (e.g., poor or regular self-rated health). These findings suggest that social inequities, already experienced by non-binary communities before the pandemic, may deepen due to the COVID-19 pandemic.

Psychological Functioning in Non-binary Identifying Adolescents and Adults

Gender diverse individuals who do not conform to society's binary gender expectations are more likely to experience difficulties in acceptance and in recognition of gender, compared to binary-identifying transgender people. This may accentuate the feeling that their gender identity is not socially recognized or validated. This study aimed to investigate psychological functioning among gender diverse adolescents and adults who identify beyond the binary gender spectrum. In both study populations, 589 clinically-referred gender diverse adolescents from the UK (n = 438 birth-assigned females and n = 151 birth-assigned males), and 632 clinically-referred gender diverse adults from the Netherlands (n = 278 birth-assigned females and n = 354birth-assigned males), we found that a higher degree of psychological problems was predicted by identifying more strongly with a non-binary identity. For adolescents, more psychological problems were related to having a non-binary gender identity and being assigned female at birth. In the adult population, experiencing psychological difficulties was also significantly related to having a stronger non-binary identity and having a younger age. Clinicians working with gender diverse people should be aware that applicants for physical interventions might have a broader range of gender identities than a binary transgender one, and that people with a non-binary gender identity may, for various reasons, be particularly vulnerable to psychological difficulties.