An exploration of the lived experiences of non-binary individuals who have presented at a gender identity clinic in the United Kingdom

Traditional and individual care pathways in gender-affirming healthcare for transgender and gender-diverse individuals - results from the ENIGI follow-up study

Treatment requests in transgender healthcare are heterogenous and not all transgender and gender-diverse individuals want to undergo the various transition-related medical interventions offered. This study aims to explore demographic and treatment-related predictors associated with different transgender care pathways in a multicenter, multinational clinical setting. In this follow-up study, 539 adult participants from Belgium, Germany, and the Netherlands took part and were categorized as following a 'traditional' care pathway (i.e., undergoing all transition-related interventions), an 'individual' care pathway (i.e. any course of treatment deviating from the traditional pathway), or 'no care' pathway (i.e. not seeking transition-related medical interventions.). We analyzed differences in demographic (e.g., gender identity) and clinical variables (e.g., treatment satisfaction), conducting logistic regression analysis and descriptive subgroup analysis. Participants with a non-binary gender were 6.7 times more likely to follow an individual care pathway, while participants with higher treatment satisfaction were less likely to follow an individual care pathway (Odds Ratio: 0.6). We identified four patterns of individual transgender care pathways, some as a function of the sex assigned at birth. The present study provides valuable insights into demographic and treatment-related predictors associated with different transgender care pathways. Healthcare providers should be aware of individual transgender care pathways and the association with (non)-binary genders to provide tailored transgender healthcare and ensure individualized, high-quality service provision.

Gendernauts in the Cistem - How Do Nonbinary People Handle Social Groups and Gender Minority Stress?

This study explores how nonbinary individuals manage minority stress within the predominantly binary society of Switzerland. Utilizing social identity theory and minority stress theory, along with thematic analysis of focus group interviews with 16 nonbinary individuals and 14 social identity maps, the study found three concentric circles of social groups: circle 1 (family, partners, friends), circle 2 (coworkers, LGBTIQA+ communities), and circle 3 (the public, media, Swiss institutions). Participants primarily felt affirmed and supported by circles 1 and 2. They reported feeling less support from circle 3 and engaged in cautious social monitoring to anticipate potential discrimination. They found discrimination from close social groups (circle 1) more distressing than from emotionally distant ones (circle 2 or 3). Our study also examined strategies employed by nonbinary participants, including monitoring others and their trans-friendliness before coming out, educating others, taking actions to make institutions more inclusive, disengaging from invalidating individuals, groups, or institutions, and searching for affirmative environments. However, these coping strategies often entail significant mental workload and exhaustion. We conclude with participant-generated recommendations to enhance nonbinary inclusion in society, politics, and healthcare. The findings underscore the need for broader societal awareness and support to mitigate minority stress experienced by nonbinary individuals.

Variant genital gender-affirming surgery: a systematic review

OBJECTIVE

To review the available literature on variant genital gender-affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes.

METHODS

A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five-criteria quality assessment checklist.

RESULTS

In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self-dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias.

CONCLUSION

This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender-diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures.

The experiences of transgender and nonbinary adults in primary care: A systematic review

BACKGROUND

Transgender and nonbinary (TNB) people face barriers to primary care, which remains the main entry point for accessing gender-affirming healthcare in the UK.

OBJECTIVES

This systematic review aims to summarise the evidence regarding TNB people's experiences of primary care to inform improvements in service and patient outcomes.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. A systematic literature search was conducted across articles from 2005 to April 2023 across Ovid Medline, Ovid Embase and PsychInfo using established keywords relating to gender identity, primary care and experiences. Qualitative data were thematically analysed and quantitative data were compiled using a descriptive narrative.

RESULTS

Following eligibility criteria, 16 articles were included in this review. This review identified both facilitators and limitations and barriers experienced by TNB people related to primary care provider knowledge; the patient-provider relationship, and healthcare settings. Quantitative findings reported up to 54.4% of participants were uncomfortable discussing TNB issues with their physician. Overall findings suggest TNB people face discrimination on a systemic level utilising primary care services, though positive healthcare encounters at a local level were reported. Participants expressed a desire for primary care-led gender-affirming healthcare services, with involvement from local TNB communities.

CONCLUSION

This review demonstrates TNB people's mixed experiences of primary care alongside their recommendations for service improvement. This is the first systematically reviewed evidence on the topic, emphasising the need for clinicians and policymakers to centre the voices of the TNB community in service design and improvement.

Conceptualizing transgender experiences in psychology: Do we have a 'true' gender?

Psychological research has acknowledged that the commonly accepted definitions of 'transgender', 'sex' and 'gender' within psychological research have resulted in limitations in accounting for the lived realities of transgender individuals. Such limitations include, but are not limited to, the continued pathologization of transgender experiences through idealizing sex and gender congruence and incapacity to account for non-normative and non-binary transition pathways. This paper provides a review of these limitations to first demonstrate how the incongruence definition of 'transgender' is reliant on the idea of a 'true' gender, and next suggest that problematising the idea of a 'true' gender allows new conceptions of transgender experiences to be advanced. To undertake this problematization, the work of Judith Butler and Sara Ahmed is used to consider how gender could be conceptualized otherwise in psychology and then applied to transgender experiences. In all, this paper theorizes transgender experiences without a reliance on the assertion of a true gender, to suggest instead a focus on contextualized transgender experiences. Last, the limitations and implications of this definition of transgender are briefly discussed. Overall, transgender experiences are conceptualized as those experiences that run counter to the dominant (re)production of binary sexed gender.

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.

Improving the integration of care for trans adults: ICTA a mixed-methods study

Background

This research concerns improving the National Health Service health services trans adults need. These include the national specialist Gender Identity Clinics that support people making a medical transition. Not all trans people need to make a medical transition, and transition can take many different paths. Waits to be seen by Gender Identity Clinics are, however, several years long, and there may be significant problems of co-ordination between different aspects of transition-related care, and between transition-related care and general health care.

Objectives

The main objectives were to understand: Which factors make services more or less accessible and acceptable to the variety of trans adults? How initiatives for providing more person-centred and integrated care can be successfully implemented and further improved?

Design, data sources and participants

An online and paper screening survey was used to gather data on demographics and service use of trans people across the United Kingdom, with 2056 responses. Researchers used survey data to construct five purposive subsamples for individual qualitative interviews, identifying groups of people more likely to experience social exclusion or stigma. There were 65 online interviews. In addition, 23 trans Black people and people of colour attended focus groups. Six case studies were completed: four on initiatives to improve care and two on experiences of particular trans populations. Fifty-five service provider staff and 45 service users were interviewed.

Results

The following undermine person-centred co-ordinated care and can lead to experiences of harm: lack of respectful treatment of trans people by general practitioner practices; inadequate funding of services; lack of support during waiting; the extended and challenging nature of Gender Identity Clinic diagnostic assessments, sometimes experienced as adversarial; breakdowns in collaboration between Gender Identity Clinics and general practitioner practices over hormone therapy; lack of National Health Service psychological support for trans people. Case studies indicated ways to improve care, although each has significant unresolved issues: training in trans health care for general practitioners; third-sector peer-support workers for trans people who come to National Health Services; gender services taking a collaborative approach to assessing what people need, clarifying treatment options, benefits and risks; regional general practitioner-led hormone therapy clinics, bringing trans health care into the mainstream; psychology services that support trans people rather than assess them.

Limitations

Some contexts of care and experiences of particular groups of trans people were not addressed sufficiently within the scope of the project. While efforts were made to recruit people subject to multiple forms of stigma, there remained gaps in representation.

Conclusions and future work

The findings have significant implications for commissioners and providers of existing National Health Services gender services, including recently established pilot services in primary care. In particular they point to the need for assessments for access to transition care to be more collaborative and culturally aware, implying the value of exploring informed consent models for accessing transition-related care. Further research is needed to investigate how far the findings apply with particular subpopulations.

Study registration

This study is registered as Research Registry, no. 5235.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/51/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 28. See the NIHR Funding and Awards website for further award information.

Words Can Hurt: A Taxonomy of Verbally Pressured Sexual Exploitation in the SES-V

This article describes the development of the Verbally Pressured Sexual Exploitation module of the Sexual Experiences Survey (SES)-Victimization (introduced by Koss et al., 2024). This module assesses the use of verbal or nonphysical, paraverbal pressure to obtain sexual acts without freely given permission. An interdisciplinary team of seven sexual exploitation researchers collaborated to create this module, with consultation from the full 15 member SES-V revision collaboration team. In this paper, we describe our process for developing this module. We briefly review empirical literature and theoretical frameworks (e.g., rape scripts, normative sexual scripts, intersectionality, and sex-positivity) that informed this work. Summary tables compare the SES-V items to verbal pressure items in prior versions of the SES and to other existing measures of violence. The comprehensive taxonomy developed herein includes six domains of Verbally Pressured sexual exploitation across 11 item stems. The components of the taxonomy include: positive verbal pressure, neutral verbal pressure, negative verbal pressure, substance-related pressure, postural violence, and threats to critical resources. The paper concludes with suggestions for future research, with priority on intersectional research that can illuminate the phenomenology and contexts of sexual exploitation against marginalized groups.

Shortcomings of transgender identity concealment research: a scoping review of associations with mental health

Background

Empirical research indicates that high rates of mental health issues in members of marginalised population groups are predicted in part by their decisions to disclose or conceal their stigmatized identities from others-a field of study known as outness research. Transgender outness research is a nascent branch of this field. It reflects neither the multidimensional view of disclosure and concealment adopted in other branches, nor the ability to address unique aspects of trans outness, such as the practical challenges of concealment and the difference between concealing one's gender identity and concealing one's assigned sex. Consequently, prior literature may not accurately represent the effects of transgender identity disclosure and concealment.

Methods

This scoping review explores the theoretical and operational definitions of trans disclosure and concealment in 46 English-language papers, identified from extensive database searches, addressing relationships between these concepts and mental health factors.

Results

Findings indicate that the issues outlined above remain unresolved, even in the widely-used nondisclosure subscale of the Gender Minority Stress and Resilience Measure, and are rarely recognized as a potential source of error. Although small detrimental effects of concealment and beneficial effects of disclosure on mental health were reported in the reviewed studies, reliable conclusions about these relationships and their importance to health and safety in the trans community cannot be drawn while these shortcomings are overlooked.

Conclusion

We encourage researchers to address these neglected areas, reevaluate the language used in measurement questions, and conduct longitudinal research to support an accurate understanding of trans outness phenomena.

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.

Practical guide to implementing patient-reported outcome measures in gender-affirming care: evaluating acceptability, appropriateness and feasibility

OBJECTIVE

Assess acceptability, appropriateness and feasibility of the Practical Guide to Implementing patient-reported outcome measures (PROMs) in Gender-Affirming Care (PG-PROM-GAC) from a sample of patients and healthcare professionals.

DESIGN

Cross-sectional study conducted August-October 2023.

SETTING

Participants were recruited from a National Health Service (NHS) gender clinic.

PARTICIPANTS

Patient participants seeking care and healthcare professionals working at an NHS gender clinic were eligible for participation. The PG-PROM-GAC was sent to participants via email for review.

OUTCOME MEASURES

Three validated tools to measure acceptability, appropriateness and feasibility were administered: the acceptability of intervention measure (AIM), intervention appropriateness measure (IAM) and feasibility of intervention measure (FIM). The percentage of participants indicating agreement or disagreement with items on the AIM, IAM and FIM was calculated.

RESULTS

A total of 132 transgender and gender diverse (TGD) patients (mean age, SD: 33, 14) and 13 gender-affirming healthcare professionals (mean age, SD: 43, 11) completed the AIM, IAM and FIM, representing a range of gender identities. The cumulative percentage of patients indicating agree or strongly agree on the AIM, IAM and FIM for the patient-relevant strategies in the PG-PROM-GAC was over 50% for each item. The cumulative percentage of patients indicating disagree or strongly disagree on the AIM, IAM and FIM for the PG-PROM-GAC was less than 20% for each item. The cumulative percentage of healthcare professionals indicating agree or strongly agree on the AIM, IAM and FIM for the healthcare professional-relevant strategies in the PG-PROM-GAC was over 38% for each item. The cumulative percentage of healthcare professionals indicating disagree or strongly disagree on the AIM, IAM and FIM for the PG-PROM-GAC was less than 15% for each item.

CONCLUSIONS

Gender-affirming healthcare professionals and TGD patients find the PG-PROM-GAC acceptable, appropriate and feasible. The PG-PROM-GAC is ready-to-use for clinicians, policy-makers and researchers committed to service improvement for gender-affirming care.

Pediatric Gender Diversity Beyond the Binary: An Exploration of Gender-Affirming Care for Nonbinary and Genderqueer Youth Seen Over Time at a Single Institution Gender Center

Purpose

The nonbinary and genderqueer (NBGQ) youth population is growing, yet scant research focuses on this distinct group. We aim to gain a deeper understanding of desired gender-affirming care and interventions pursued by NBGQ youth.

Methods

A retrospective chart review of NBGQ patients seen at the University of California, San Francisco Child and Adolescent Gender Center from January 1, 2009, to December 31, 2020, was performed. Demographic information, desired gender-affirming care, and gender-affirming interventions pursued at initial and most recent visits were collected.

Results

Initial visit charts of 116 NBGQ youth who attended more than one clinic visit were reviewed. In total, 48 unique genders were documented; gender evolved over time for some youth, as did desired gender-affirming care. At the most recent visit, 15 youth (12.9%) had a binary gender, and 101 youth (87.1%) had an NBGQ gender. At the initial visit, 56 youth (48.3%) were interested in gender-affirming hormone therapy, compared with 75 youth (65.6%) at the most recent visit. In addition, 21 (18.1%) and 49 (42.2%) youth were interested in surgery at the initial and most recent visits, respectively. In general, interest in interventions was higher than pursuit of interventions.

Conclusion

There is vast diversity of gender and differences in desired gender-affirming care within the NBGQ youth population. Desires for gender-affirming care within the cohort changed over time, and not all those who expressed a desire for an intervention received it. The reasons are likely multifactorial, highlighting the need for expectation-free and patient-specific affirming care and research on the NBGQ youth population, while also considering barriers to care.

"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.

Outcomes of Gender-Affirming Voice and Communication Modification Training for Non-binary Individuals: A Case Series

OBJECTIVES

There is currently no research reporting solely on outcomes of voice and communication modification training (VCMT) in individuals who identify as non-binary and genderqueer (NBGQ) in the English literature. This study aimed to describe the objective and subjective impact of VCMT on the voice of NBGQ individuals undergoing a 12-week gender-affirming VCMT program.

METHODS

A retrospective consecutive case series of NBGQ individuals enrolled in a VCMT program was performed. Demographics, Transgender Self-Evaluation Questionnaire (TSEQ), fundamental frequency (F0), and frequency range were collected before and after the program.

RESULTS

Four NBGQ individuals enrolled between January 2019 and June 2021; the mean age was 27.0 years. While all four participants represented in this case series showed improvement in at least one of their initial goals, only one improved both their F0 and TSEQ scores; the other three participants had mixed results.

CONCLUSION

NBGQ individuals experienced improvements in self-reported outcomes and changes in acoustic measures after completing VCMT in our case series. Individuals experienced significant improvement in subjective outcomes despite small changes in acoustic measures, and vice versa. More research is needed to better understand the voice and communication needs of NBGQ individuals, along with their outcomes with VCMT.

LEVEL OF EVIDENCE

Level 4.

Prospective Evaluation of Psychosocial Changes After Chest Reconstruction in Transmasculine and Non-Binary Youth

PURPOSE

This study sought to prospectively examine the effects of gender-affirming chest reconstruction on gender congruence and chest dysphoria in transmasculine and nonbinary adolescents and young adults.

METHODS

Individuals between the ages of 15-35 who were seeking gender-affirming chest surgery were enrolled as part of a broader, longitudinal study of transgender surgical experiences. Their chest dysphoria and gender congruence were measured at baseline, six months, and one year, using the Transgender Congruence and Chest Dysphoria scales. Repeated measures analysis of variance were used to detect differences in scores across assessment points. Where there were significant differences indicated, Tukey's honestly significant difference test was used to determine which differences in mean scores were significant between assessment points, as well as how results differed by demographic factors.

RESULTS

The analytical sample consisted of 153 individuals who had completed both the baseline and at least one follow-up assessment - 36 (24%) endorsing a nonbinary gender and 59 (38%) under the age of 18. Repeated measures analysis of variance indicated significant differences in gender congruence, appearance congruence, and chest dysphoria between at least two assessment points for the total sample and each subgroup (binary/non-binary and adult/minor). Honestly significant difference tests indicated no significant differences between the postoperative assessments by age or binary gender.

DISCUSSON

Gender-affirming chest reconstruction improves gender and appearance congruence and reduces chest dysphoria in both non-binary and binary populations of adolescents and young adults. These data support the need to improve access to gender-affirming chest reconstruction for adolescents and young adults and to remove legislative and other barriers to care.

Nonbinary gender identities

A description of the meaning and terminology as well as population estimates of nonbinary gender identities is given. Respectful use of language, names and pronouns of people who identify as nonbinary is discussed. The chapter further includes the need for access to gender-affirming care and barriers to care; gender-affirming medical treatment interventions, including hormone treatment, speech and language therapy, hair removal and surgeries for bodies assigned female at birth (AFAB) and for bodies assigned male at birth (AMAB); and the importance of fertility preservation for this specific patient population.

Exploring the Experiences of Autistic Transgender and Non-Binary Adults in Seeking Gender Identity Health Care

Background

This study sought to obtain an in-depth understanding of autistic transgender and/or non-binary adults' experiences in accessing, or trying to access, gender identity health care (GIH). To our knowledge, no prior study researched this topic.

Methods

Through semi-structured interviews, we obtained the first-hand experiences of 17 participants. H.B. (cisgender, non-autistic) conducted a reflexive thematic analysis using an inductive approach, in collaboration with K.M., an autistic transgender disability community researcher, and under the supervision of S.K.K., a cisgender autistic autism researcher.

Results

Thematic analysis determined that poor knowledge of professionals, accessibility issues, and bureaucratic and economic barriers impacted participants' experiences when accessing GIH. Participants experienced a perceived lack of professional knowledge around autism and gender diverse health care needs, limited communication methods and accommodations, and misdiagnosis of mental health difficulties. Accessibility issues included unmet sensory needs, disruption to routine, and a lack of local provision. Further, participants shared that they struggled with unclear processes, standardization of care, long waiting lists, and confusing or inaccessible insurance coverage. Recommendations for improvements highlighted the need to listen to service users to positively impact their experiences in accessing GIH.

Conclusion

This study suggests that more training needs to be given to health care providers and professionals around autistic experience to help improve providers' competence in communication and providing person-centered accommodations. More training around gender diverse identities is needed, as well as increased knowledge on the co-occurrence of autism and transgender/non-binary identities, to positively impact patient experiences and help improve access to care.

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.

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.

(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.

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.

Psychosis in transgender and gender non-conforming individuals: A review of the literature and a call for more research

Epidemiological studies have described higher rates of psychotic disorder diagnoses in transgender, as compared to cisgender, individuals. With the exception of this work and a small number of published case studies, however, there has been little consideration of gender diversity in psychosis research or clinical care. In this paper, we will review and critically evaluate the limited literature on gender diversity and clinical psychosis and articulate the critical need for more work in this field, more specifically on the following areas and how they bear on clinical care: 1) diagnostic biases; 2) how chronic non-affirmation and bias, gender dysphoria, and other gender minority stressors may operate as trauma and can contribute to clinically significant psychotic symptoms; 3) the potential impact of gender-affirming care, such as hormone therapies, on mental health and barriers for receiving such care in transgender and nonbinary individuals; and 4) culturally-sensitive and gender-affirming approaches for addressing psychosis. Finally, we consider ways in which researchers may engage in ethical, gender-affirming, and accurate approaches to better address gender identity in psychosis research. We hope that such research will aid in the creation of clinical guidelines for understanding, diagnosing, and treating psychosis in gender diverse individuals.

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.

Dramaturgical Accounts of Transgender Individuals: Impression Management in the Presentation of Self to Specialist Gender Services

Demand for gender dysphoria (GD) treatment has increased markedly over the past decade. Access to gender-affirming treatments is challenging for most people. For dysphoric individuals, much is at stake. Little is known about the specific needs, challenges, and coping strategies of this hard-to-reach group. We examined the experiences of treatment-seeking adolescents and adults using in-depth unstructured interviews with 26 people attending specialist gender services and 14 transgender people not referred to services. Patients with gender dysphoria distrust clinical services and describe considerable anxiety in sustaining their impression management strategies to obtain treatment. An authentic presentation is regarded by some participants, especially non-binary individuals, as inauthentic and emotionally difficult to maintain. Impression management strategies have partial success in accessing services. The presentation of "idealized" selves may result in unmet mental health needs of patients, and the receipt of interventions incongruent with their authentic selves.

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.

Accessing and utilising gender-affirming healthcare in England and Wales: trans and non-binary people's accounts of navigating gender identity clinics

BACKGROUND

Transgender, or trans, people experience a number of barriers to accessing gender-affirming healthcare and have a range of barriers and facilitators to primary care and specialist services, commonly citing discrimination and cisgenderism playing a central role in shaping accessibility. The pathway through primary care to specialist services is a particularly precarious time for trans people, and misinformation and poorly applied protocols can have a detrimental impact on wellbeing.

METHOD

We recruited trans participants from an HIV Self-Testing Public Health Intervention (SELPHI) trial to interviews which explored contemporary gender-affirming service experiences, with an aim to examine the path from primary care services through to specialist gender services, in the UK.

RESULTS

A narrative synthesis of vignettes and thematic analysis of in-depth qualitative interviews were conducted with twenty trans individuals. We summarise positive and negative accounts of care under three broad categories: Experiences with primary care physicians, referrals to gender identity clinics (GICs), and experiences at GICs.

CONCLUSIONS

We discuss implications of this research in terms of how to improve best practice for trans people attempting to access gender-affirming healthcare in the UK. Here we highlight the importance of GP's access to knowledge around pathways and protocols and clinical practice which treats trans patients holistically.

"It's like my kid came back overnight": Experiences of trans and non-binary young people and their families seeking, finding and engaging with clinical care in England

Background

Trans and non-binary children and young people in England, UK struggle to gain access to affirming clinical care, despite the international research evidence pointing toward this best practice approach. Concurrently, they are subject to constant discussion in the UK national media and politics, where many negative assumptions are made about their needs, experiences and clinical provision. Their journey to seek appropriate care has not yet been documented.

Aims

We trace the experiences of trans and non-binary children and youth and their families in their decision to seek, searches for and experiences with affirmative and non-affirmative clinical input for help with their gender.

Method

27 dyadic, semi-structured interviews were undertaken with trans and non-binary children and young people and their parents from 13 families.

Results

The process of seeking support via National Health Service clinical routes in England, UK is beset with lengthy waiting lists, issues with geographical inaccessibility, a lack of relevant clinical knowledge, and a failure to recognize the value of family expertise. Family doctors provide contraceptive hormones in lieu of proper access to puberty blocking or gender affirming hormones, and most families resort to private care they can ill afford.

Discussion

Training in gender identity and gender dysphoria is recommended for both family doctors, and children's mental health services. Gender identity development services could be decentralized, with local hubs offering more accessible support.

The terminology of identities between, outside and beyond the gender binary - A systematic review

Background: Recently, a multitude of terms have emerged, especially within North America and Western Europe, which describe identities that are not experienced within the culturally accepted binary structure of gender which prevails within those cultures. As yet, there is no clear single umbrella term to describe such identities and a mixture of words have been used in scholarly work to date. Aims: To explore the origins and track the emergence of newer terms and definitions for identities between, outside and beyond the gender binary, to outline current trends in descriptors within scholarly work and to suggest a term which is wide enough to encompass all identities. Methods: A comprehensive systematic review was made, following the PRISMA guidelines. Several relevant key terms were used to search Web of Science, ScienceDirect, PubMed, and the International Journal of Transgenderism. The descriptions each title gives for identities outside of the binary are extracted for analysis. Results: Several terms have been used over the years to describe identities outside of the binary. "Non-binary" and "genderqueer" are currently mostly used as umbrella terms. However, "gender diverse" is emerging as a more suitable wide-ranging inclusive term for non-male and non-female identities. Discussion: Identity outside of "male" and "female" is an emerging concept which currently has several identifiers and little academic agreement on which is the most pertinent. The two leading descriptors are "non-binary" and "genderqueer." Gender diverse is emerging as a new term which has the aim of including all other terms outside of male and female within it and this article suggests the increase in its use to describe gender identities outside of the binary.

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

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

Health of Non-binary and Genderqueer People: A Systematic Review

Background: Non-binary and genderqueer (NBGQ) people are those who do not identify within the gender binary system (male vs. female), not falling exclusively in man/male or woman/female normative categories. A higher proportion of NBGQ people is usually found within young persons. This population is marginalized and, as such, is at risk of stigmatization and of developing negative health outcomes. As literature on the health of NBGQ people is sparse, this study aims at systematically review the limited studies on this field. Methods: The research questions which guided the systematic review were: (1) What are the differences in the health levels between NBGQ and binary transgender (BT) individuals? (2) What are the differences in the health levels between NBGQ and cisgender individuals? (3) Which medical and psychological interventions are most suitable for improving NBGQ health? According to PRISMA guidelines, a systematic search was conducted in PubMed, PsycInfo, Web of Science, and Google Scholar. Results: Eleven studies met the inclusion criteria for the current systematic review. Among them, 9 were focused on the health differences between NBGQ and BT individuals, 4 of the latter and 1 individually were focused on the health differences between NBGQ and cisgender individuals, and 1 was focused on the evaluation of health outcomes related to medical procedures. No studies assessed psychological interventions aimed at improving health in NBGQ individuals. All studies were cross-sectional, did not generally recruit a large sample of NBGQ individuals, and used non-probability sample design. Results related to the difference in health between NBGQ and BT were mixed; indeed, some found a better health status while others a worse one. Results related to the differences in health between NBGQ and cisgender highlighted higher health needs in NBGQ than in BT individuals. The only study analyzing the effects of medical interventions on health found that NBGQ female-assigned at birth individuals improved their quality of life after chest surgery. Conclusions: Although scholars are starting to pay attention to the NBGQ health, research needs to be expanded both in terms of methodology and research contents. Clinical, health-related social policies, and research recommendations in this field are reported.

Gender congruence and body satisfaction in nonbinary transgender people: A case control study

Background: Binary transgender people access gender affirming medical interventions to alleviate gender incongruence and increase body satisfaction. Despite the increase in nonbinary transgender people, this population are less likely to access transgender health services compared to binary transgender people. No research has yet understood why by exploring levels of gender congruence and body satisfaction in nonbinary transgender people. Objective: The aim of this study was to compare levels of gender congruence and body satisfaction in nonbinary transgender people to controls [binary transgender people and cisgender (nontrans) people]. Method: In total, 526 people from a community sample in the UK took part in the study (97 nonbinary, 91 binary, and 338 cisgender identifying people). Participants were asked to complete an online survey about gender congruence and body satisfaction. Results: There were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender and body satisfaction compared to binary transgender people. However, there was no difference in congruence and satisfaction with social gender role between the two transgender groups (nonbinary and binary). Cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary). Conclusions: There are differences in gender congruence and body satisfaction between nonbinary and binary transgender people. Nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people. Transgender health services need to be more inclusive of nonbinary transgender people and their support and treatment needs, which may differ from those who identify within the binary gender system.