A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary

Clinicians Report Less Comfort in Provision of Medical Care to Nonbinary Transgender Youth

Purpose

The purpose of this study was to determine whether clinician comfort differs in the provision of gender-affirming medical care to transgender and gender diverse (TGD) youth with binary versus nonbinary gender identities.

Methods

A cross-sectional survey was distributed to three international health professional electronic mailing lists. Comfort providing gonadotropin-releasing hormone agonist (GnRHa) and gender-affirming hormone therapy (GAHT) to nonbinary and binary TGD youth was assessed using 5-point Likert scales and analyzed with Wilcoxon signed-rank tests. Logistic regression modeling comfort providing GnRHa and GAHT to nonbinary compared to binary TGD youth was performed to identify relevant predictors.

Results

Fifty-five respondents completed the survey. Respondents reported more comfort providing both GnRHa therapy and GAHT to binary compared to nonbinary TGD youth. In univariate analyses, being in a pediatric endocrinology specialty and work within a multidisciplinary clinic setting were associated with less comfort providing GAHT to nonbinary compared to binary TGD youth. Non-straight/non-heterosexual sexual orientation, being in a general pediatrics specialty, and higher estimated percentage of nonbinary TGD youth cared for in clinical practice were associated with more comfort. Only nonstraight/nonheterosexual sexual orientation maintained significance after adjusting for potential confounders in multivariate analyses.

Conclusions

Clinicians are less comfortable providing gender-affirming medical care to nonbinary versus binary TGD youth. Efforts to decrease barriers and to inform development of clinical practice guidelines inclusive of nonbinary TGD youth are needed.

Prevalence, severity and risk factors for mental disorders among sexual and gender minority young people: a systematic review of systematic reviews and meta-analyses

Evidence suggests heightened prevalence and severity of mental disorders among sexual minority (SM) and gender minority (GM) young people. Several risk factors have been associated with these disparities. A systematic review of systematic reviews and meta-analysis was conducted to provide a comprehensive overview of the literature and to determine the field's current position. MEDLINE, PsycInfo, Scopus and Web of Science were searched in March 2022 and updated January 2024. Eligibility criteria were systematic reviews or meta-analyses assessing contemporaneous prevalence, severity and/or risk factors of mental disorders among SM or GM young people aged 25 and under. 42 reviews were included, all of which were low quality. The prevalence of depression among SM was 26% (95% CI 21-32%), and among GM was 46% (95% CI 36-56%). Greater depression severity was found among SM compared to heterosexual young people, with a significant albeit small effect size (Hedges' g = 0.38, 95% CI = 0.25 to 0.50); effect sizes were similar when separating by gender. GM also reported greater symptom severity compared to cisgender young people. Other mental disorders were more prevalent compared to those reported in the general population, and of greater severity compared to heterosexual/cisgender young people. Several proximal and distal risk factors were focused upon within the systematic reviews identified. Past systematic reviews consistently indicate a heightened risk of mental disorders among SM and GM young people. Services need to be aware of these disparities and adapt their care accordingly.

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.

Digital mental health service engagement changes during Covid-19 in children and young people across the UK: Presenting concerns, service activity, and access by gender, ethnicity, and deprivation

The adoption of digital health technologies accelerated during Covid-19, with concerns over the equity of access due to digital exclusion. The aim of this study was to assess whether service access and presenting concerns differed before and during the pandemic. Sociodemographic characteristics (gender, ethnicity, and deprivation level) were examined to identify disparities in service use. To do this we utilised routinely collected service data from a text-based online mental health service for children and young people. A total of 61221 service users consented to sharing their data which represented half of the service population. We used interrupted time-series models to assess whether there was a change in the level and rate of service use during the Covid-19 pandemic (April 2020-April 2021) compared to pre-pandemic trends (June 2019-March 2020) and whether this varied by sociodemographic characteristics. The majority of users identified as female (74%) and White (80%), with an age range between 13 and 20 years of age. There was evidence of a sudden increase (13%) in service access at the start of the pandemic (RR 1.13 95% CI 1.02, 1.25), followed by a reduced rate (from 25% to 21%) of engagement during the pandemic compared to pre-pandemic trends (RR 0.97 95% CI 0.95,0.98). There was a sudden increase in almost all presenting issues apart from physical complaints. There was evidence of a step increase in the number of contacts for Black/African/Caribbean/Black British (38% increase; 95% CI: 1%-90%) and White ethnic groups (14% increase; 95% CI: 2%-27%), sudden increase in service use at the start of the pandemic for the most (58% increase; 95% CI: 1%-247%) and least (47% increase; 95% CI: 6%-204%) deprived areas. During the pandemic, contact rates decreased, and referral sources changed at the start. Findings on access and service activity align with other studies observing reduced service utilization. The lack of differences in deprivation levels and ethnicity at lockdown suggests exploring equity of access to the anonymous service. The study provides unique insights into changes in digital mental health use during Covid-19 in the UK.

Transgender and Gender-Diverse Minority Stress and Substance Use Frequency and Problems: Systematic Review and Meta-Analysis

The goal of this preregistered study was to systematically review and meta-analyze quantitative research examining relationships between minority stress (distal stress, expectations of gender-based rejection, concealment of gender identity, and internalized transphobia) and substance use (alcohol use frequency and problems, and drug use frequency and problems) in transgender and gender-diverse (TGD) samples. Searches of PsycInfo, MEDLINE, Gender Studies, and LGBTQ+ Source databases were conducted for quantitative articles that included effect sizes for cross-sectional associations between TGD-based minority stress and substance use outcomes. Random-effects meta-analyses were used to compute effect sizes for 16 minority stressor-substance use variable pairs. Moderator analyses were conducted for publication year and proportion of the sample assigned female sex at birth, identified as Black, Indigenous, or people of color (BIPOC), or identified as a sexual minority. Thirty-six studies with 76 effect sizes were included. Significant correlations were observed for relationships between distal stress and alcohol use frequency (r=0.13; 95% confidence interval [CI]=0.06 to 0.20) and problems (r=0.09; 95% CI=0.03 to 0.14), and drug use frequency (r=0.16; 95% CI=0.11 to 0.21) and problems (r=0.14; 95% CI=0.05 to 0.23). No associations for proximal minority stress-substance use variable pairs were significant. Effect sizes for associations between distal stress and alcohol use frequency were higher in samples with more BIPOC participants (z=4.27, p<0.001, R 2=0.740). Findings indicate that distal, but not proximal, minority stress was significantly associated with drug and alcohol use frequency and problems. Theoretical and clinical implications are discussed.

Sexual and Gender Identity Properties and Associations With Physical and Mental Health Among SGM Midlife and Older Adults: Findings From Aging With Pride: National Health, Aging, and Sexuality/Gender Study

Objectives: Unidimensional measures of sexual and gender identity are most often used in research. Yet, sexuality and gender are defined by complex characteristics. Guided by the Health Equity Promotion Model, we assess multidimensional properties of sexual and gender identity. Methods: This study utilizes 2016 survey data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS) to investigate properties of identity (affirmation, visibility, centrality, integration, congruence, continua, transformation) and their association with multimorbidity, disability, general health, depression, quality of life among SGM adults (N = 2233), 50 and older. Results: Higher affirmation, centrality, congruence, and transformation were associated with better health, while identity integration and continua were associated with some adverse health outcomes. Bisexual men, sexually diverse and transgender individuals had the lowest identity centrality and visibility. Discussion: The findings necessitate a multidimensional approach to identity and the use of measures that are comprehensive and responsive to sexual and gender diversity.

Experiences of body image in the gender non-binary community: A qualitative analysis

Body image concerns are prevalent within transgender communities - many transgender people engage in disordered eating to suppress or accentuate secondary sex characteristics and reduce gender dysphoria. However, this research has mostly been conducted with binary transgender people. Here, we examine how non-binary people experience and relate to their bodies. Semi-structured one-on-one interviews were conducted with 13 gender non-binary individuals living in Australia. Photo elicitation techniques were utilised, and the transcribed interview data were analysed using reflexive thematic analysis. Six themes were identified: Expansive Understandings of Body Image, Body Image can be Linked to Gender Dysphoria, Cultivating a Preferred Body can Lead to Gender Euphoria, Appreciating Diversity in Non-Binary Body Ideals, The Androgynous Body Ideal is not Universally Accepted, and Experiencing the Body as Functional rather than Aesthetic. The present findings highlight the diversity of experiences of body image for non-binary people. The non-binary concept of body image was found to be expansive, stressing various physical attributes involved in social gender recognition and physiological sources of gender dysphoria. Some participants valued gender-affirming medical intervention, others were accepting of their bodies as they are, attributing their body confidence to the process of affirming their non-binary gender.

[Adolescents with Gender Incongruence - Special Case Constellations]

Adolescents with Gender Incongruence - Special Case Constellations Abstract: Adolescents with gender incongruence and gender identity variants have a high rate of accompanying mental disorders, such as depression, autism spectrum disorders, or eating disorders. Yet, the interaction between gender incongruence, gender dysphoric distress, and accompanying mental disorders is complex and varies considerably from case to case. We need an individualized approach and careful professional assessment to help those affected and their guardians make informed decisions regarding possible treatment steps in complex case constellations. Maintaining careful process support and planning of the treatment steps can help to resolve blocked development processes in adolescents with gender incongruence and accompanying psychological disorders or in young people with unstable gender identity development.

Mental health of non-binary youth: a systematic review and meta-analysis

BACKGROUND

Non-binary identities are increasingly recognized within the spectrum of gender diversity, yet there is a dearth of research exploring the mental health challenges specific to this population. Therefore, this systematic review and meta-analysis aimed to comprehensively assess the mental health outcomes of non-binary youth in comparison to their transgender and cisgender peers.

METHODS

A systematic search was conducted to identify relevant studies across three electronic databases (PubMed, Scopus, Web of Science) covering the period from inception to October 2023. The meta-analysis was performed employing a random-effects model. Inclusion criteria encompassed studies comparing non-binary youth with transgender or cisgender youth, providing data on mental health outcomes such as general mental health, depressive and anxiety symptoms, self-harm and suicidality.

RESULTS

Twenty-one studies, meeting the inclusion criteria and originating from six different countries, were included in the analysis. The sample encompassed 16,114 non-binary, 11,925 transgender, and 283,278 cisgender youth, with ages ranging from 11 to 25 years. Our meta-analysis revealed that non-binary youth exhibit significantly poorer general mental health compared to both transgender (d = 0.24, 95% CI, 0.05-0.43, p =.013) and cisgender youth (d = 0.48, 95% CI, 0.35-0.61, p <.001), indicating a more impaired general mental health in non-binary youth. Regarding depressive symptoms, when comparing non-binary and cisgender individuals, a moderate and significant effect was observed (d = 0.52, 95% CI, 0.41-0.63, p <.001). For anxiety symptoms, a small but significant effect was observed in the comparison with cisgender individuals (d = 0.44, 95% CI, 0.19-0.68, p =.001). Furthermore, non-binary individuals exhibited lower rates of past-year suicidal ideation than transgender peers (OR = 0.79, 95% CI, 0.65-0.97, p =.023) and higher rates of lifetime suicidal ideation than cisgender youth (OR = 2.14, 95% CI, 1.46-3.13, p <.001).

CONCLUSION

Non-binary youth face distinct mental health challenges, with poorer general mental health, elevated depressive and anxiety symptoms compared to cisgender, and similar rates of self-harm and suicidal behavior compared to transgender individuals. These findings underscore the urgent need for targeted interventions, including gender-affirming mental health support, to address the specific needs of non-binary youth.

Two-Year Follow-Up Study of Health-Related Quality of Life Among Transgender and Gender Expansive Youth Receiving Gender-Affirming Care

Purpose

To examine changes in health-related quality of life (HRQOL), this 2-year follow-up study reassessed the HRQOL of transgender and gender expansive (TG/GE) young people enrolled in a patient registry at the Gender Wellness Center (GWC) in upstate New York.

Methods

Registry patients had to have a gender-affirming care follow-up visit at the GWC within a 2 year window (+6 months) of their baseline survey to complete follow-up. Youth <18 years of age completed the Child Health Questionnaire-Child Form 87 (CHQ-CF87); youth >18 years of age completed the Short Form-36v2 (SF-36v2). We analyzed change from baseline to follow-up for 11 CHQ-CF87 subscales and 8 SF-36v2 subscales. We compared follow-up HRQOL results to U.S. population standards. We abstracted receipt of gender-affirming care from GWC electronic medical records.

Results

Among the 173 patients who completed HRQOL assessments at baseline, 108 completed follow-up (62% response rate) from May 2019 to March 2022. The mean age for those completing the CHQ-CF87 was 14.6±2.2 years (range 10-17) and for the SF-36v2 was 19.7±2.3 years (range 18-24). CHQ-CF87 Behavior and Role/Social Physical Functioning subscale scores improved significantly among youth 8-17 years of age from baseline. Follow-up SF-36v2 scores for patients 18-24 years of age did not change significantly. Follow-up HRQOL mental health scores remained statistically significantly lower than U.S. population standards for both age groups.

Conclusions

Two year follow-up HRQOL data from TG/GE youth receiving gender-affirming care improved in two domains, but did not change among young adults (>18 years of age). Mental health remains suboptimal compared to national standards.

Changes in Stress, Depression, and Anxiety Symptoms in a Brazilian Sample During Quarantine Across the Early Phases of the COVID-19 Crisis

OBJECTIVE

We aimed to estimate prevalence and incidence of stress, depression, and anxiety symptoms in Brazilians during the COVID-19 pandemic.

METHOD

We assessed 103 (54 women, 49 men) participants online in three periods of the pandemic: March 2020 (T1), April 2020 (T2), and June 2020 (T3). Estimates of prevalence and incidence were identified when mental health scores were two standard deviations above the mean compared to normative data. Mental health indicators were measured using the Perceived Stress Scale, the Filgueiras Depression Index, and the State-Trait Anxiety Inventory - State Subscale.

RESULTS

At T1, 89% of individuals were below cut-off scores for stress, anxiety, and depression, which dropped to 35% by T3. Estimated stress prevalence was 1.9% at T1, 7.8% at T2, and 28.2% at T3. Estimated depression prevalence was 0% at T1, 23.3% at T2, and 25.2% at T3. Estimated state anxiety prevalence was 10.7% at T1, 11.7% at T2, and 45.6% at T3. Stress incidence increased by 7.8% from T1 to T2, and 23.3% from T2 to T3. Depression incidence increased by 23.3% from T1 to T2, and 15.5% from T2 to T3. Anxiety incidence increased by 9.7% from T1 to T2, and 39.8% from T2 to T3. Stress severity scores significantly increased from 16.1 ± 8.7 at T1 to 23.5 ± 8.4 at T2, and 30.3 ± 6.0 at T3. Depression severity scores significantly increased from 48.5 ± 20.5 at T1 to 64.7 ± 30.2 at T2, and 75.9 ± 26.1 at T3. Anxiety increased from 49.0 ± 13.4 at T1 to 53.5 ± 12.5 at T2 and 62.3 ± 13.4 at T3. Females had significantly higher anxiety scores than males by T3 (66.7 ± 11.8 vs. 57.4 ± 13.5).

CONCLUSION

Prevalence and incidence of stress, depression, and anxiety significantly increased throughout the pandemic. The largest increase in stress and anxiety occurred between T2 and T3, and between T1 and T2 for depression. Severity of stress, depression, and anxiety increased throughout the study.

Mental health and timing of gender-related events among transgender and gender-diverse children and adolescents seeking gender-affirming consultation and care

Transgender and gender-diverse (TGD) youth encounter unique challenges affecting their mental health, largely related to societal stigma and gender dysphoria. Limited research considers the specific needs of TGD youth. This study examined demographic and developmental factors, including the ages at which gender-related events occur, and their relationship to mental health among TGD youth seeking gender-affirming consultation and care (GACC). We examined the medical records of 674 TGD children and adolescents, comparing demographics, gender-related events, and mental health across gender groups. The total sample comprised 261 patients assigned male at birth, and 413 patients assigned female at birth. Non-binary individuals reported higher rates of psychopathology compared to binary transgender patients, with transgender boys exhibiting higher rates than transgender girls. Seeking GACC at a more advanced pubertal stage and older age was associated with an increased likelihood of psychopathology. Later recollection of first gender incongruence memory was correlated with higher rates of depression and anxiety. Finally, socioeconomic status was linked to GACC healthcare-seeking behaviors. These findings underscore the importance of recognizing the diverse experiences and needs of TGD youth seeking GACC services, highlighting that early identification and access to care may be crucial for improving mental health outcomes.

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.

Parental Support, Depressive Symptoms, and LGBTQ Adolescents: Main and Moderation Effects in a Diverse Sample

OBJECTIVE

Research has documented the importance of parental support as a protective factor against depressive symptoms among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth. In this study, we assessed the relations between LGBTQ-specific parental support and depressive symptoms.

METHOD

Participants were 6,837 LGBTQ youth (ages 13-17) with diverse racial and ethnic, gender, and sexual identities. Main effect and moderation analyses examined interactions between LGBTQ-specific parental support with demographic variables on depressive symptoms, considering demographics as moderators.

RESULTS

We found that participants of color reported less LGBTQ-specific parental support than their White counterparts, that transgender and genderqueer participants reported less LGBTQ-specific parental support than their cisgender counterparts, and that non-monosexual participants reported less LGBTQ-specific parental support than their monosexual counterparts. Disparities in depressive symptoms were found for individuals who identified as Native American and Latinx, non-monosexual, and transgender and genderqueer, such that these groups reported higher levels of depressive symptoms. Further, we found a significant interaction between LGBTQ-specific parental support and ethnicity, with LGBTQ-specific parental support being less strongly associated with participants who identified as Latinx compared to those who did not identify as Latinx. We also found a significant interaction between LGBTQ-specific parental support and gender identity, with LGBTQ-specific parental support being more strongly related to depressive symptoms among participants who did not identify as boys compared to cisgender boys .

DISCUSSION

We discuss how to assess the impact of interlocking systems of oppression when working with LGBTQ youth and their parental figures.

Nonbinary identity and pronoun use: A qualitative analysis

Background and Aims

Limited psychological research focuses on the identities and pronoun use experiences of nonbinary and genderqueer people. The purpose of this qualitative study was to examine the experiences of nonbinary and genderqueer young people, particularly with respect to the use and significance of pronouns.

Method

Twenty nonbinary people between the ages of 18 and 28 were recruited through flyers, queer student groups, and social media to take part in an interview and brief demographic survey. Interview transcripts were analyzed using inductive thematic analysis.

Results

Four overarching themes were selected: "Beyond Binary Gender Restrictions," "Pronouns as a Tool," "Pronouns and Outness," and "Nonbinary Enough." Participants reported finding strength in their gender nonconformity while balancing complicated demands from their communities and from society at large. They also described their pronouns as playing important roles in social relationships and in identity affirmation.

Discussion

The diverse roles that pronouns play in the lives of nonbinary people illustrates the need for increased conversation and flexibility in using people's pronouns. Results suggest that supporting nonbinary identities requires increased understanding, respect, and more active forms of allyship from cisgender individuals, including moving beyond conceptualizing gender as a binary.

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.

Young adults from disadvantaged groups experience more stress and deterioration in mental health associated with polycrisis

The recent polycrisis (COVID-19, Ukraine war, climate change, economic crisis) has been associated with mental health through cumulative stress, with young people being particularly vulnerable. We surveyed 403 college students from Poland to examine their psychological responses to the experienced crises. The results showed that polycrisis was associated with worse mental health of college students from disadvantaged groups (based on gender, sexual orientation, and financial situation) compared to other college students, in four areas: sense of proximity to the crises, stress caused by the crises, sense of responsibility for mitigating the crises, and experiencing everyday moral dilemmas regarding the crises. These young adults also suffered more in terms of negative affectivity, depressive symptoms, and subjective physical and mental health. Our findings suggest that when discussing public mental health perspectives, it is important to consider consequences of cumulative stress and its greater impact on young people from disadvantaged groups.

Autistic Traits, Gender Minority Stress, and Mental Health in Transgender and Non-Binary Adults

The present study investigated the relation between autistic traits and gender minority stress and the relative importance of autistic traits and gender minority stress in predicting mental health outcomes in gender minority adults. An online survey was completed by 90 transgender women, 72 transgender men, 48 non-binary individuals assigned male at birth (AMAB), and 98 non-binary individuals assigned female at birth (AFAB). Autistic traits positively correlated with internalised transphobia in the non-binary groups. In general, higher autistic traits and gender minority stress correlated with poorer mental health outcomes. After controlling for gender minority stress, autistic traits accounted for additional variance of suicidality across gender minority groups, anxiety symptoms in the non-binary groups, and all mental health outcomes in non-binary AFAB.

Risk and protective factors for self-harm thoughts and behaviours in transgender and gender diverse people: A systematic review

Background

Self-harm (any self-injury or -poisoning regardless of intent) is highly prevalent in transgender and gender diverse (TGD) populations. It is strongly associated with various adverse health and wellbeing outcomes, including suicide. Despite increased risk, TGD individuals' unique self-harm pathways are not well understood. Following PRISMA guidelines we conducted the first systematic review of risk and protective factors for self-harm in TGD people to identify targets for prevention and intervention.

Methods

We searched five electronic databases (PubMed, PsychInfo, Scopus, MEDLINE, and Web of Science) published from database inception to November 2023 for primary and secondary studies of risk and/or protective factors for self-harm thoughts and behaviours in TGD people. Data was extracted and study quality assessed using Newcastle-Ottawa Scales.

Findings

Overall, 78 studies published between 2007 and 2023 from 16 countries (N = 322,144) were eligible for inclusion. Narrative analysis identified six key risk factors for self-harm in TGD people (aged 7-98years) were identified. These are younger age, being assigned female at birth, illicit drug and alcohol use, sexual and physical assault, gender minority stressors (especially discrimination and victimisation), and depression or depressive symptomology. Three important protective factors were identified: social support, connectedness, and school safety. Other possible unique TGD protective factors against self-harm included: chosen name use, gender-identity concordant documentation, and protective state policies. Some evidence of publication bias regarding sample size, non-responders, and confounding variables was identified.

Interpretation

This systematic review indicates TGD people may experience a unique self-harm pathway. Importantly, the risk and protective factors we identified provide meaningful targets for intervention. TGD youth and those assigned female at birth are at increased risk. Encouraging TGD people to utilise and foster existing support networks, family/parent and peer support groups, and creating safe, supportive school environments may be critical for self-harm and suicide prevention strategies. Efforts to reduce drug and alcohol use and experiences of gender-based victimisation and discrimination are recommended to reduce self-harm in this high-risk group. Addressing depressive symptoms may reduce gender dysphoria and self-harm. The new evidence presented in this systematic review also indicates TGD people may experience unique pathways to self-harm related to the lack of social acceptance of their gender identity. However, robust longitudinal research which examines gender-specific factors is now necessary to establish this pathway.

Analyzing body dissatisfaction and gender dysphoria in the context of minority stress among transgender adolescents

BACKGROUND

Gender dysphoria among transgender adolescents has predominantly been examined in relation to body dissatisfaction. While in adult transgender samples, body dissatisfaction is higher than in cisgender controls, this has so far rarely been investigated for adolescents. In the context of a cisnormative society, the impact of influences from the social environment on body dissatisfaction and gender dysphoria has been neglected in research. Therefore, this study aimed to (1) provide a detailed analysis of body dissatisfaction among young transgender people and (2) investigate whether body dissatisfaction and gender dysphoria are associated with experiences of minority stress such as trans hostility and poor peer relations (PPR).

METHODS

The paper presents a cross-sectional study among a sample of transgender adolescents, presenting at a specialized outpatient counseling clinic (N = 99; age M = 15.36, SD = 1.85). First, body dissatisfaction (assessed by the Body-Image-Scale; BIS), was explored and compared to data from a population-based control group of cisgender peers (N = 527; age M = 14.43, SD = 0.97). Second, within a clinic-referred transgender subsample (n = 74), associations between body dissatisfaction and gender dysphoria (measured by Utrecht Gender Dysphoria Scale; UGDS), PPR (measured by the Youth-Self-Report; YSR-R), and trans hostile experiences (assessed in clinical interview) were examined by correlations, t-tests and multivariate regression.

RESULTS

Transgender adolescents reported more body dissatisfaction than cisgender peers. The dissatisfaction with sex characteristics, non-hormonal reactive body regions and the total score for body dissatisfaction were positively related with gender dysphoria. The majority had experienced trans hostility in the present and/or past (54.1%) and PPR (63.5%). More body dissatisfaction was correlated with more PPR regarding visible body parts i.e., hair, overall appearance and muscles, whilst PPR and gender dysphoria were not associated. Transgender adolescents who experienced trans hostility showed higher gender dysphoria and PPR, but not more body dissatisfaction. In multiple regression, trans hostility predicted gender dysphoria, whilst age and PPR predicted body dissatisfaction.

DISCUSSION

Experiences of minority-stress differentially interact with body dissatisfaction and gender dysphoria among transgender adolescents. Social correlates of body dissatisfaction and gender dysphoria must be considered when working with young transgender people.

Binary and Non-binary Gender Identities, Internalizing Problems, and Treatment Wishes Among Adolescents Referred to a Gender Identity Clinic in Germany

Clinical research on transgender and gender-nonconforming (TGNC) adolescents has focused on binary individuals or often not differentiated among gender identities. Recent studies suggest that a considerable proportion of TGNC adolescents identify as non-binary and that these youth report more internalizing problems as well as different transition-related medical treatment wishes than binary adolescents. However, the results are inconclusive, and data for the German-speaking area are lacking. Therefore, the present study aimed to assess the percentage of binary and non-binary gender identities in a German sample of clinically referred TGNC adolescents and examine associations of gender identity with internalizing problems and transition-related medical treatment wishes. The sample consisted of 369 adolescents (11-18 years, Mage = 15.43; 305 birth-assigned female, 64 birth-assigned male) who attended the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS) between 2013 and 2019. Gender identity and treatment wishes were assessed using study-specific items and internalizing problems using the Youth Self-Report. In total, 90% (n = 332) of the sample identified as binary and 10% (n = 37) as non-binary. Having a non-binary gender identity was significantly associated with more internalizing problems and with wishing for no transition-related medical treatment or only puberty-suppressing hormones. The results underscore that non-binary adolescents represent a specifically vulnerable subgroup within TGNC adolescents with unique mental health needs and treatment wishes. Future research should differentiate among various gender identities. In clinical practice, it is crucial to create an inclusive space for non-binary youth and provide mental health care if needed.

[Gender Experiences of Transgender Youth: How Changeable is the Gender Experience of Binary vs. Nonbinary Identifying Transgender Youth and What Factors Are Involved?]

Gender Experiences of Transgender Youth: How Changeable is the Gender Experience of Binary vs. Nonbinary Identifying Transgender Youth and What Factors Are Involved? Abstract: Objectives: Nonbinary gender identities are becoming increasingly visible in transgender healthcare and research. However, little is known about the various gender identities of transgender adolescents - whether they are stable or fluid and which factors influence their gender experience. The present study investigates these different aspects of gender in transgender adolescents with various gender identities. Method: The sample comprised a recent cohort of 114 adolescents diagnosed with gender dysphoria (GD) attending the Hamburg Gender Identity Service for Children and Adolescents (Hamburg GIS). We used the Gender Diversity Questionnaire to assess the different aspects of gender. Results: In total, 83 % of the sample reported a binary (BI) and 17 % a nonbinary gender identity or were still questioning their gender identity (NBGQ). 15-18 % of the transgender adolescents reported gender fluidity. The NBGQ group reported significantly higher levels of gender fluidity or more often that their gender identity was still open to change, respectively, than the BI group. Puberty (79 %), physical distress (70 %), and social media (36 %) were the most frequently mentioned factors influencing their gender experience. Conclusions: The present study underscores that gender experience is not binary and fixed for all transgender adolescents, but that, in some cases, it may be nonbinary or fluid. This heterogeneity, the possible fluidity, and the puberty-related physical distress may challenge treatment decisions in transgender adolescents diagnosed with GD. This situation highlights the importance of developing individualized treatment plans.

Nonbinary people: Perceived social support in personal relationships and (virtual) communities

Background

Nonbinary individuals grapple with societal and individual pressures from a pervasive lack of comprehension, acknowledgment, and affirmative social representation. This dearth of a societal conversation recognizing the validity of nonbinary identities leads to instances of discrimination. Social support is recognized as a buffer to these experiences and is positively related to better physical and psychological health.

Aims

To explore the processes nonbinary people experienced with their most significant relationships, be it romantic, friendships, and/or family members, before and after disclosure of nonbinary identification. Additionally, we sought to contextualize their participation, or nonparticipation, in activist groups and virtual communities.

Methods

The present study adopts a qualitative methodology to build an initial understanding of the perceived social support of non-binary people in Portugal. We conducted non-structured life story interviews with thirty-three Portuguese nonbinary people and analyzed the collected data using thematic analysis.

Results

The findings are illustrated by two main themes: the Flow of Relational Support, where we explored the support perceived or not by the most significant relationships; and The Search and Find of Community Support, where we characterized the search and find of support through the participation in activist and virtual communities/groups.

Discussion

The current findings illustrate the positive influence of perceived social support on the experiences of nonbinary individuals. Of note, these experiences were highly diverse, with no participants reporting comprehensive support from all the sources explored. Additionally, the detrimental impact of perceiving a lack of support in some critical areas remained prominent. Individuals struggled to gain recognition and validation, resulting from a lack of relational support and a reluctance to seek out and find community support. Nonbinary individuals confront intense scrutiny and prejudice from the broader social sphere, compromising their ability to live openly.

Social Support for Rural Gender Diverse Youth Compared to Cisgender Peers

PURPOSE

Gender diverse youth (GDY) experience higher rates of mental health concerns than their cisgender peers, but these can be ameliorated by feeling support from family, school, and community. Little is known about how youth perceptions of support vary by gender identity, especially for younger adolescents and those living in rural areas.

METHODS

Youth ages 12-19 years completed anonymous surveys including measures of perceived support and a two-step gender identity question. GDY (n = 206) were further categorized into binary and nonbinary gender identities. An additional 500 randomly selected cisgender youth were included for comparison. Multivariate analyses of variance with Tukey post hoc tests were employed to test GDY group differences while accounting for the interaction between scaled measures.

RESULTS

Cisgender youth had the highest perceived support across all support measures while youth who shared both binary and nonbinary aspects of their gender identity had the lowest rates of perceived support. The F tests for between-subject effects were statistically significant (p <.001) for all six support measures, and multivariate group testing was statistically significant with Wilks' λ 6.38(18,1621.17) = 0.82; p <.001.

DISCUSSION

Despite research demonstrating a strong association between perceived support and improved mental health outcomes, GDY in our sample had lower rates of perceived support at the family, school, and community levels. GDY with both binary and nonbinary gender identities had the lowest levels of perceived support. Further research is needed to see if this finding is consistent in other populations and to develop targeted interventions to improve perceived support for this population.

The "triple whammy": Serious psychological distress, suicidal ideation, and substance misuse among transgender persons

PURPOSE

This paper examines the conjoint effects of serious psychological distress, suicidal ideation, and substance abuse among transgender adults. The principal aims are to determine the prevalence of this "triple whammy," identify the factors underlying the co-occurrence of all three problems, and to determine if there is evidence of syndemic effects underlying the "triple whammy."

METHODS

Data from the 2015 U.S. National Transgender Survey were used to examine the "triple whammy" relationship in a sample of 27,715 transgender Americans aged 18 or older. Odds ratios and multivariate logistic regression were performed to examine the data.

RESULTS

13.3 % of the study participants reported experiencing serious psychological distress, suicidal ideation, and substance abuse. The most potent predictors of the "triple whammy" were younger age, a greater number of anti-transgender experiences, and not reaching various transition milestones. Strong evidence emerged to indicate the presence of syndemic effects in operation.

CONCLUSIONS

Experiencing the combination of adverse mental health and substance abuse was not uncommon in this population of transgender adults. Being young, experiencing a larger variety of types of anti-transgender discrimination, harassment, and violence, and not reaching specific transition milestones all had a significant impact on the odds that people would experience the "triple whammy." This was particularly true when these measures were examined in conjunction with one another, because of strong syndemic effects.

Testing the minority stress model across gender identity, race, and ethnicity among U.S. gender minority adolescents

Gender minority (GM) youth are at heightened risk for psychopathology, purportedly due to their experiences of GM stressors. However, few studies have examined how GM stressors are associated with depression and anxiety among GM youth. Furthermore, no prior studies have investigated how experiences of GM stressors differ across gender identity and race/ethnicity within a diverse sample of GM youth. A nationwide online cross-sectional survey of 1,943 fourteen- to 18-year-old GM adolescents (66.91% White, 11.73% multiracial, 8.49% Latinx, 7.10% Black, 3.09% Asian, 1.49% American Indian/Alaskan Native) in the United States assessed GM stressors (prejudice events, expectations of rejection, internalized transnegativity, and concealment) and mental health. Structural equation modeling was used to examine how GM stressors and depressive and anxiety symptoms differ across gender identity and race/ethnicity. Higher levels of each GM stressor were related to higher depressive symptoms. Prejudice events, expectations of rejection, and concealment were related to higher anxiety symptoms. Transmasculine and transfeminine youth reported higher levels of GM prejudice events and expectations of rejection, and higher mental health symptoms, than nonbinary youth. Findings were relatively consistent across racial/ethnic identities, with the exception that Black GM adolescents reported fewer GM prejudice events and expectations of rejection and indirectly exhibited lower mental health symptoms as compared to White GM youth. Researchers and clinicians should be attuned to how intersectional identities are related to stress and mental health among diverse GM youth. Recommendations for individual and structural-level interventions are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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

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

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.

The Role of Family Support and Dyadic Adjustment on the Psychological Well-being of Transgender Individuals: An Exploratory Study

Introduction

This study aimed to measure dyadic adjustment, social support, and psychological well-being.

Methods

A research protocol composed of the Dyadic Adjustment Scale, the Outcome Questionnaire 45.2, and the Multidimensional Scale of Perceived Social Support was administered to a sample of 109 Italian transgender individuals.

Results

Higher levels of global psychological distress, symptom severity, and interpersonal relationship distress were associated with lower levels of family support and dyadic adjustment. In addition, transgender women and younger transgender individuals reported higher levels of interpersonal relationship distress.

Conclusions

The results indicate that the support and acceptance of one's partner and family of origin play a crucial role in promoting well-being. It represents an important protective factor with respect to negative psychological health outcomes.

Policy Implications

The findings emphasize the need to develop specific clinical and social practices for transgender individuals and their families. Building family and partner-centered policies and programs is particularly important to enable transgender individuals to avoid paying the emotional and psychological costs associated with rejection and non-acceptance.

Social Support and Mental Health Among Transgender and Nonbinary Youth in Quebec

Purpose: Transgender and nonbinary (TNB) youth face elevated levels of discrimination, stigma, mental health disorders, and suicidality when compared with their cisgender counterparts. Family and school support may mitigate some of the effects of the stressors facing TNB youth. This study aimed to better understand the impact of each of these sources of support on TNB youths' mental health and wellbeing. Methods: We used data collected between 2018 and 2019 as part of the Canadian Trans Youth Health Survey, a bilingual online survey to measure social support, physical health, and mental health in a sample of 220 TNB youth aged 14-25 living in Québec, Canada. We examined the relationships among different sources of support, and mental health and wellbeing outcomes using logistic regression. Analyses were conducted on the full sample and according to linguistic groups (French and English). Results: Participants reported high levels of mental health symptoms, self-harm, and suicidality, and mental health symptoms were higher in the English-speaking group (p = 0.005). In models controlling for age, family connectedness was associated with good/excellent self-reported mental health (odds ratio [OR] = 2.62, p = 0.001) and lower odds of having considered suicide (OR = 0.49, p = 0.003) or attempted suicide (OR = 0.43, p = 0.002), whereas school connectedness was associated with higher odds of good/very good/excellent general (OR = 2.42, p = 0.013) and good/excellent mental (OR = 2.45, p = 0.045) health. Conclusion: Family and school support present consistent associations with TNB youths' health and may constitute key areas for intervention for those supporting them.

Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients

BACKGROUND

Transgender and gender diverse (TGD) individuals experience more severe psychological distress and may be at higher risk for suicide compared to cisgender individuals. The existing literature largely consists of small-sample studies that do not assess subgroup differences.

OBJECTIVE

To examine rates of self-reported suicidal ideation among four TGD groups compared to cisgender individuals.

DESIGN

Data were extracted from the electronic health records of patients receiving primary care at a community health center specializing in sexual and gender minority health. A logistic regression was used to examine the relationship between sociodemographic variables and the presence of current suicidal ideation.

PARTICIPANTS

29,988 patients receiving care at a community health center in Northeastern US between 2015 and 2018.

MAIN MEASURES

Demographic questionnaire, 9-item Patient Health Questionnaire KEY RESULTS: Younger age, sexual and gender minority identity, and public/grants-based insurance were associated with significantly higher odds of suicidal ideation. Relative to cisgender men, transgender men (OR=2.08; 95% CI=1.29-3.36; p=.003), transgender women (OR=3.08; 95% CI=2.05-4.63; p<.001), nonbinary (NB) individuals assigned male at birth (AMAB; OR=3.55; 95% CI=1.86-6.77; p<001), and NB individuals assigned female at birth (AFAB; OR=2.49; 95% CI=1.52-4.07; p<001) all endorsed significantly higher odds of current suicidal ideation, controlling for age, race, ethnicity, sexual orientation, and insurance status. Larger proportions of transgender women (23.6%) and NB AMAB individuals (26.7%) reported suicidal ideation not only compared to cisgender men (6.1%) and women (6.6%), but also compared to transgender men (17.4%; χ2[5, n=25,959]=906.454, p<0.001).

CONCLUSIONS

TGD patients were at significantly increased risk of suicidal ideation, even after accounting for age, race, ethnicity, sexual orientation, and insurance status. Findings suggest distinct risk profiles by assigned sex at birth. Consistent assessment of and intervention for suicidal ideation should be prioritized in settings that serve TGD patients.

Associations Among Gender-Affirming Hormonal Interventions, Social Support, and Transgender Adolescents' Mental Health

PURPOSE

We aimed to examine the concurrent associations of gender-affirming hormonal interventions (i.e., puberty blockers, testosterone, estrogen), as well as family and friend social support, on transgender and nonbinary (TNB) adolescents' reports of anxiety symptoms, depressive symptoms, nonsuicidal self-injury (NSSI), and suicidality. We hypothesized that gender-affirming hormonal interventions and greater social support would be associated with lower levels of mental health concerns.

METHODS

Participants (n = 75; aged 11-18; M_age = 16.39 years) were recruited for this cross-sectional study from a gender-affirming multidisciplinary clinic. Fifty-two percent were receiving gender-affirming hormonal interventions. Surveys assessed anxiety and depressive symptoms, NSSI and suicidality in the past year, and social support from family, friends, and significant others. Hierarchical linear regression models examined associations between gender-affirming hormonal interventions and social support (i.e., family, friend) with mental health while accounting for nonbinary gender identity.

RESULTS

Regression models explained 15%-23% of variance in TNB adolescents' mental health outcomes. Gender-affirming hormonal interventions were associated with fewer anxiety symptoms (β = -0.23; p < .05). Family support was associated with fewer depressive symptoms (β = -0.33; p = .003) and less NSSI (β = -0.27; p = .02). Friend support was associated with fewer anxiety symptoms (β = -0.32; p = .007) and less suicidality (β = -0.25; p = .03).

DISCUSSION

TNB adolescents had better mental health outcomes in the context of receiving gender-affirming hormonal interventions and having greater support from family and friends. Findings highlight the important role of quality family and friend support for TNB mental health. Providers should aim to address both medical and social factors to optimize TNB mental health outcomes.

International Association of Forensic Nurses. Gender-Affirming Care and Comprehensive Sexuality Education

ABSTRACT

Every year, an estimated 246 million children are subject to some form of gender-based violence, including mistreatment, bullying, psychological abuse, and sexual harassment. Lesbian, gay, bisexual, transgender, two-spirit, or questioning youth are at a heightened risk of experiencing violence and have unique health, educational, and social needs. Fostering an atmosphere of support and acceptance can help alleviate many of these negative outcomes.

Predictors of self-harm and suicide in LGBT youth: The role of gender, socio-economic status, bullying and school experience

BACKGROUND

Lesbian, gay and bisexual (LGB) young people's increased risk of self-harm, suicidal attempts and suicide compared with heterosexual youth is well established. The current study sought to examine whether these findings also apply to the trans (T) population and which factors act as additional risk or protective factors.

METHODS

In a national cross-sectional survey, 3713 LGBT adolescents, aged 11-19 years, reported on their own history of self-harm, suicidal ideation and suicide attempts, as well as their experiences of school and homophobic, biphobic and transphobic bullying. Logistic regressions tested the association between risk and protective factors on self-harm, suicidal ideation and suicide attempts.

RESULTS

A high proportion of the sample reported self-harm (65.3%), suicidal ideation (73.8%) and suicide attempts (25.7%). Demographic risk factors included identifying as female, non-binary or trans and being from a low-income background. Bullying and online bullying were associated with an increased risk for each outcome, and positive school experience was associated with a reduced risk for each outcome.

CONCLUSIONS

Consistent with minority stress theory, the study found high rates of mental health problems within LGBT youth. Interventions focused on improving young people's experiences in schools appear useful targets to help improve mental health outcomes.

The moderating effect of physical activity on the relationship between bullying and mental health among sexual and gender minority youth

BACKGROUND

Sexual and gender minority youth frequently experience bullying, which often contributes to higher depressive symptoms and lower self-esteem. Given that physical activity (PA) can mitigate depressive symptoms and improve self-esteem, we examined the moderating effect of PA on the relationship between bullying and mental health among sexual and gender minority youth.

METHODS

Data from the Lesbian, Gay, Bisexual, Transgender, and Queer National Teen Survey (n = 9890) were analyzed. Hierarchical regression analyses examined the influence of history and frequency of being bullied, PA, and the interaction of these variables on depressive symptoms and self-esteem. Simple slopes analyses were used to probe significant interactions.

RESULTS

Results indicated the importance of accounting for bullying history when examining effects of PA on mental health. PA was negatively related to depression (t = -4.18, p < 0.001) and positively related to self-esteem (t = 12.11, p < 0.001). Bullying frequency was positively related to depression (t = 19.35, p < 0.001) and negatively related to self-esteem (t = -12.46, p < 0.001). There was a significant interaction between bullying frequency and PA for depression (t = 4.45, p < 0.001) and self-esteem (t = -4.69, p < 0.001). Post hoc analyses suggested that the positive effects of PA on mental health may be limited to those not bullied because it had a negligible effect on those who were bullied.

CONCLUSION

Results suggest that sexual and gender minority youth exercise interventions aiming to improve mental health should first address bullying history; otherwise, their effectiveness may be limited to those who have been bullied.

Social Support as a Buffer of the Association between Sexual Assault and Trauma Symptoms Among Transgender and Gender Diverse Individuals

The prevalence of experiencing sexual assault is alarmingly high among Transgender and Gender Diverse people (TGD; people whose gender identities and/or expressions are not traditionally associated with their sex assigned at birth) and is associated with various mental health sequalae. Perceived social support has been shown to abate the negative outcomes of sexual assault among cisgender individuals, yet little is known about this association among TGD people, especially which provider of support (i.e., family, friends, or significant others) may be most beneficial. To that end, 191 TGD adults were recruited through Amazon's Mechanical Turk to examine perceived social support as a potential moderator of the association between sexual assault victimization and post-sexual assault trauma symptomology. Results showed an interaction trending toward significance between sexual assault and support from a significant other. Decomposition of this interaction demonstrated that sexual assault was associated with post-assault trauma symptoms when support from a significant other was low (ß = .25, p < .05) but not high (ß = .10, p = .089). The interaction between sexual assault and perceived social support was not significant for perceived support from friends (p = .133) or family (p = .954). Findings highlight the need for additional research on perceived social support as a potential buffering mechanism between sexual assault and post-assault symptomology in TGD people.

Sex Chromosome Rearrangement Associated With Hormonal Abnormalities and Gender Dysphoria

Although disorders arising from sex chromosome and sex steroid abnormalities are well characterized from the perspectives of endocrinology, dysmorphology, and reproductive health, relatively little is known about neuropsychiatric development, gender identity, incongruence, and dysphoria in the populations with these disorders. In this report, we describe the case of a 21-year-old gender nonbinary individual identified as male at birth who presented to an academic psychiatry consultation clinic because of life-long gender dysphoria. The patient was found to have a complex sex chromosomal rearrangement and associated hormonal abnormalities that may, at least in part, explain the patient's history. In addition to describing a novel genetic change, this case and the accompanying review of the existing literature highlight the need for an increased focus on the psychiatric perspective, and sex and gender issues in particular, among all patients with sex chromosome abnormalities and inborn errors of steroid metabolism.

Gender-affirming endocrine care for youth with a nonbinary gender identity

Nonbinary individuals, or those who identify outside of the traditional gender binary, are currently present in up to 9% of the general population of youth or up to 55% of gender-diverse youth. Despite the high numbers of nonbinary individuals, this population continues to experience barriers to healthcare due to providers' inability to see beyond the transgender binary and lack of competence in providing nonbinary care. In this narrative review, we discuss using embodiment goals to individualize care of nonbinary individuals, and review hormonal and nonhormonal treatment options for gender affirmation. Hormonal treatments include those often used in binary transgender individuals, such as testosterone, estradiol, and anti-androgens, but with adjustments to dosing or timeline to best meet a nonbinary individual's embodiment goals. Less commonly used medications such as selective estrogen receptor antagonists are also discussed. For nonhormonal options, alterations in gender expression such as chest binding, tucking and packing genitalia, and voice training may be beneficial, as well as gender-affirming surgeries. Many of these treatments lack research specific to nonbinary individuals and especially nonbinary youth, and future research is needed to ensure safety and efficacy of gender-affirming care in this population.

Non-Binary Clients' Experiences of Psychotherapy: Uncomfortable and Affirmative Approaches

Non-binary people may face specific challenges in psychological settings. Psychotherapists often display a lack of preparation for non-binary gender identities, resulting in overt or subtle forms of prejudice that compromise the therapeutic alliance. The present study aimed to provide data on non-binary clients' positive and negative experiences within therapeutic relationships. Twenty-five interviews were conducted with non-binary people in the age range of 19-35. Using codebook thematic analysis, the researchers identified three main themes: (1) the self of the psychotherapist, consisting of the impact of the therapist's personal (i.e., sexual identity) and professional (i.e., competence) characteristics on the therapeutic experience; (2) the practice of the psychotherapist, emerging as affirmative (validation and microaffirmations) or negative (gender identity change efforts, manifest aggressions, and microaggressions) approaches toward non-binary identities; (3) the therapeutic relationship, referring to the alliance, rupture, and reparation based on the therapists' openness toward non-binary identities. To provide a safer setting for non-binary clients, psychotherapists should incorporate issues related to gender minority identities in their training, acknowledge clinical errors when they occur and adopt an active predisposition to learn through the client's experience, giving value to their unique contribution.

Mental health among sexual and gender minorities: A Finnish population-based study of anxiety and depression discrepancies between individuals of diverse sexual orientations and gender minorities and the majority population

Substantial empirical evidence suggests that individuals who belong to sexual and gender minorities experience more anxiety and depression than heterosexual and cisgender people. Many previous studies have not, however, used population-based samples. There is also a shortage of evidence about certain sexual and gender minorities (e.g., nonbinary individuals). We examined differences in levels of anxiety and depression within sexual and gender minorities, as well as compared to the heterosexual and cisgender majority in a population-based Finnish sample (N = 8,589). We also explored if individuals who belong to both a gender and a sexual minority (double minority) reported higher rates of anxiety and depression than individuals who hold either a gender or a sexual minority status (single minority). Individuals who belonged to either a sexual or a gender minority overall experienced significantly higher rates of anxiety and depression than cisgender and heterosexual individuals. Among the different sexual and gender minorities, bisexual, emerging identity, and nonbinary individuals reported the highest rates of anxiety and depression. We found no differences in anxiety and depression between single minority and double minority individuals. Our results suggest that even though Finland is a country with an inclusive social climate, sexual and gender minorities are, nevertheless, disproportionately affected by mental health issues. The present study gives further support to the claim that individuals holding a sexual or gender minority status experience higher levels of depression and anxiety compared to cisgender and heterosexual individuals and pinpoints the need to acknowledge these issues both in the context of health care and in the society at large.

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.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students

BACKGROUND

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.

METHODS

Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.

RESULTS

Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.

CONCLUSIONS

AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

Factors Associated with Non-Binary Gender Identity in Psychiatric Inpatients with Suicidal Ideation Assigned Female at Birth: A Case-Control Study

The study aimed to investigate factors associated with non-binary gender identity in Russian female psychiatric inpatients with suicidal ideation. This case-control study included 38 female inpatients with non-binary gender identity and a control group-76 cisgender women matched for age (age range 19-35 years, M age, 21.5 years); both groups were psychiatric inpatients with suicidal thoughts. All patients underwent the Self-Injurious Thoughts and Behaviors Interview and completed the brief Reasons for Living Inventory. We also used the WHO Quality of Life Questionnaire (WHOQOL-100) and the Life Style Index (LSI). Non-binary gender identity in inpatients with suicidal ideation was associated with lower educational level, higher unemployment rate, being more socially reticent in preschool, and lifetime sexual experience with both male and female partners. In addition, they were younger at the time of the first suicidal ideation, suicide plan development, and attempt. Non-binary inpatients had lower scores in freedom, physical safety, and security facets of WHOQOL-100 and a higher level of intellectualization on LSI. People with non-binary gender identity face educational, employment, and communication issues. They also have distinct suicidal thoughts and behavioral profiles. These issues and differences mean unique approaches to suicide prevention for a population of inpatients with non-binary gender identity are needed.

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.

Experiences with Menses in Transgender and Gender Nonbinary Adolescents

STUDY OBJECTIVE

To describe menstrual history, associated dysphoria, and desire for menstrual management in transgender male and gender diverse adolescents who were assigned female at birth DESIGN: Retrospective chart review SETTING: Tertiary care children's hospital PARTICIPANTS: All patients seen in a multidisciplinary pediatric gender program from March 2015 through December 2020 who were assigned female at birth, identified as transgender male or gender nonbinary, and had achieved menarche INTERVENTION: None MAIN OUTCOME MEASURES: Patient demographics, menstrual history, interest in and prior experiences with menstrual management, parental support, and concerns about menstrual management RESULTS: Of the 129 included patients, 116 (90%) identified as transgender male and 13 (10%) as gender nonbinary, with an average age of 15 (SD 1.6) years. Almost all (93%) patients reported menstrual-related dysphoria. Most (88%) were interested in menstrual suppression. The most common reasons for desiring suppression were achievement of amenorrhea (97%) and improvement of menstrual-related dysphoria (63%).

CONCLUSIONS

Most gender diverse patients assigned female at birth reported dysphoria associated with menses and desired menstrual suppression. This information can encourage physicians to raise this topic and offer menstrual management for gender diverse patients who experience distress related to menses, especially for those who are not ready for or do not desire gender-affirming hormonal treatment. Future research is needed to better understand patients' experiences with menses and to determine the optimal menstrual management methods. This could be an important intervention to improve outcomes for this vulnerable population.

Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people

PURPOSE

Muscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study.

METHODS

We evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18-74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study.

RESULTS

Using a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating.

CONCLUSIONS

These findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.