Breaking down barriers and binaries in trans healthcare: the validation of non-binary people

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

INTRODUCTION

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

METHODOLOGY

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

DISCUSSION

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

CONCLUSION

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

Factors associated with primary healthcare provider access among trans and non-binary immigrants, refugees, and newcomers in Canada

Objective

Trans and non-binary (TNB) immigrants, refugees, and newcomers (IRN) face intersecting challenges and barriers, including stigma and persecution in countries of origin, and others unique to the Canadian resettlement process. The present study aimed to investigate factors that are associated with having a primary healthcare provider among TNB IRN.

Design

Trans PULSE Canada was a community-based, national study of health and wellbeing among 2,873 TNB people residing in Canada, aged 14 and older, who were recruited using a multi-mode convenience sampling approach.. The survey asked questions about identity, community, service access, health - and IRN were asked questions specific to immigration/settlement.

Results

Of the 313 IRN participants who completed the full survey version (age M = 34.1, SE=0.75), 76.4 % had a primary healthcare provider. TNB IRN largely reported being Canadian citizens (59.8 %), gender non-binary or similar (46.9 %), currently living in Ontario (35.5 %), and having immigrated from the United States (32.1 %). Chi-square analyses revealed that having a primary healthcare provider was associated with age, gender identity, citizenship status, region of origin, current location in Canada, length of time since immigrating to Canada, status in gender affirming medical care, and having extended health insurance. With modified Poisson regression, we found that TNB IRN who were non-permanent residents, originating from European, African, and Oceania regions, or living in Quebec and the Prairie provinces were less likely to have a primary healthcare provider.

Conclusion

Results may inform settlement organizations of the unique needs and barriers of TNB IRN. Schools and LGBTQ+ organizations may better serve this population - especially those originating from highlighted regions, who live in Quebec or the Prairie provinces, and/or are non-permanent residents - by offering programs that connect them to primary healthcare providers who are competent in cross-cultural trans health.

Exploring Gender Diversity in Transgender and Non-Binary Adults Accessing a Specialized Service in Italy

In Italy, studies investigating gender identity and expression in gender non-conforming adults are lacking, as well as data regarding the non-binary population. The present study aimed at dimensionally exploring how transgender and non-binary Italian adults identify and express their gender. The Gender Diversity Questionnaire (GDQ) was administered to a sample of 112 adult subjects aged 18-60 years accessing a gender-specialized service in Rome. The majority of the participants were aged 18-24 years (53.6%), whereas fewer subjects were aged 25-35 years (32%) and 35 years and older (14.3%). Most participants (83.9%) identified themselves as trans binary, while the remaining (16.1%) identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity over time and across contexts. Younger subjects recognized the use of chosen names, pronouns, and clothes as important for their gender expression, whereas older subjects attributed more importance to physical appearance and emotions. Differences regarding gender-affirmative interventions emerged between non-binary and transbinary participants. Findings evidence that gender non-conforming adults accessing gender-specialized services have unique needs and features, thus it is essential to shed light on this population by providing greater visibility and recognition.

Caring for nonbinary patients

ABSTRACT

Nonbinary is an umbrella term that encompasses any person whose gender identity is outside the binary construct of man or woman . An estimated 1.2 million people in the United States identify as nonbinary, a number that most likely will continue to increase as the visibility of people who live outside binary gender increases in our society. Healthcare providers are likely to encounter nonbinary patients but may lack confidence in treating these patients appropriately. This article describes terminology, concepts, and suggestions for clinicians to provide basic respectful and competent care for nonbinary patients.

Gender-Affirming Hormone Therapy for the Trans, Gender Diverse, and Nonbinary Community: Coordinating World Professional Association for Transgender Health and Informed Consent Models of Care

Purpose

Before commencing gender-affirming hormone therapy, people undergo assessments through the World Professional Association for Transgender Health (WPATH) model (typically with a mental health clinician), or an informed consent (IC) model (without a formal mental health assessment). Despite growing demand, these remain poorly coordinated in Australia. We aimed to compare clients attending WPATH and IC services; compare binary and nonbinary clients; and characterize clients with psychiatric diagnoses or longer assessments.

Methods

Cross-sectional audit of clients approved for gender-affirming treatment (March 2017-2019) at a specialist clinic (WPATH model, n=212) or a primary care clinic (IC model, n=265). Sociodemographic, mental health, and clinical data were collected from electronic records, and analyzed with pairwise comparisons and multivariable regression.

Results

WPATH model clients had more psychiatric diagnoses (mean 1.4 vs. 1.1, p<0.001) and longer assessments for hormones (median 5 vs. 2 sessions, p<0.001) than IC model clients. More IC model clients than WPATH model clients were nonbinary (27% vs. 15%, p=0.016). Nonbinary clients had more psychiatric diagnoses (mean 1.7 vs. 1.1, p<0.001) and longer IC assessments (median 3 vs. 2 sessions, p<0.001) than binary clients. Total psychiatric diagnoses were associated with nonbinary identities (β 0.7, p=0.001) and health care cards (β 0.4, p=0.017); depression diagnoses were associated with regional/remote residence (adjusted odds ratio [aOR] 2.2, p=0.011); and anxiety disorders were associated with nonbinary identities (aOR 2.8, p=0.012) and inversely associated with employment (aOR 0.5, p=0.016).

Conclusion

WPATH model clients are more likely to have binary identities, mental health diagnoses, and longer assessments than IC model clients. Better coordination is needed to ensure timely gender-affirming care.

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

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

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

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

Intonation Parameters in Gender Diverse People

OBJECTIVES/HYPOTHESIS

Although intonation is often addressed in speech training for gender diverse individuals, the relationship between intonation and femininity/masculinity ratings remains unclear. The aim of this study was to examine differences in intonation parameters in gender diverse individuals. Moreover, the relationship between acoustic intonation parameters and femininity/masculinity ratings was investigated.

METHODS

Speech samples of semistructured speech were elicited from cisgender (cis) (107 ciswomen, 104 cis men), transgender (trans) (19 trans women, 10 trans men), and non-binary (n = 11) individuals using a prosody protocol. An objective acoustic analysis was performed to compare intonation parameters (upward/downward/flat intonation shift, general and final intonation shift, general fundamental frequency range, fundamental frequency variation index) between groups. In addition, a listening experiment was conducted, consisting of a cis and gender diverse listening panel (n = 41). The listeners were asked to rate the femininity/masculinity of speech samples (n = 57) using a visual analogue scale. Correlational analyses were used to examine the relationship between intonation parameters and femininity/masculinity ratings.

RESULTS

Similarity was found in the intonation parameters of participants with a similar gender identity. In non-binary speakers, no significant differences in acoustic intonation parameters were found between these speakers and the cisgender speakers. In addition, no significant correlations were found between the acoustic intonation parameters and the femininity/masculinity ratings in the groups with cis men, cis women, and non-binary participants. However, moderate to strong significant correlations were found between acoustic intonation parameters and femininity/masculinity ratings in the trans participants.

CONCLUSIONS

Intonation is a "speech marker" that distinguishes between groups with a different gender identity. No relationship was observed between intonation and femininity/masculinity ratings for cisgender and non-binary speakers. However, the significant relationship between these parameters for transgender participants (trans men and trans women) provides evidence for intonation exercises in gender affirming voice, speech, and communication training, and therefore contribute to evidence-based intonation training in transgender persons.

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.

Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals

BACKGROUND

As the field of gender-affirming care continues its advancement, a clinical gap in the definition and evaluation of sexual function in transgender and non-binary (TGNB) individuals is becoming increasingly apparent. Recent speculations propose the modification of cis-gender heteronormative sexual function measurement tools as a useful way to close this knowledge gap.

METHODS

Although the use of previously validated tools creates an easier platform for modification, the assumption of cis-gender sexual function as baseline will further disrupt patient-provider relationships, leading to inaccurate scientific conclusions, and increase the healthcare barriers faced by this community.

RESULTS

As the definition of health has grown to include sexual function, the responsibility of the physician has evolved to include the treatment of sexual dysfunction as well. Without the imminent establishment of a scientific definition of sexual function with an accompanying measurement tool, this lack of understanding continues a precedent that may further stigmatize and distance this population from healthcare. Although this challenge may seem daunting, it should be noted that this has been accomplished for both cis-gender heterosexual men and women. This failure to scrupulously address the needs of the TGNB community directly contradicts the medical profession's revered values of equity and compassion. This branch of sexual medicine and gender-affirming care is critical for maximizing the quality of life as well as equity of the TGNB community to their cis-gender, heteronormative counterparts.

CONCLUSION

A careful, kinder, and more inclusive approach is necessary, and the TGNB community deserves optimized care which requires a uniquely developed definition of sexual function and the required measurement tools. Whitney N., Samuel A., Douglass L., et al. Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals. J Sex Med 2022;19:1032-1034.

Toward Nonbinary Nuance in Research and Care: Mapping Differences in Gender Affirmation and Transgender Congruence in an Online National U.S. Survey

Purpose: To close gaps in transgender health research, we mapped trends in gender affirmation processes (i.e., social, legal, and psychological transitions) that are unique among nonbinary (NB) transgender adults when compared with transgender women (TW) and transgender men (TM).

Methods: Data were drawn from the Columbia Trans Empowerment Survey (N=707), an online national study conducted between 2014 and 2015 in the United States. We used one-way analysis of variance tests, chi-square tests, Kruskal–Wallis tests, and post hoc analyses to estimate differences in gender affirmation processes and transgender congruence between: (1) NB adults, n=271, 38%; (2) TW, n=291, 41%; and (3) TM, n=145, 21%. We then identified bivariate correlations between variables of interest.

Results: In the full sample (n=707), we found significant positive bivariate correlations between pursuing gender affirmation and transgender congruence. In terms of demographics, NB participants were significantly more likely to be queer (42.1%), polyamorous (25.5%), unemployed (44.8%), and younger (median=22) than TW and TM. They also reported taking significantly fewer gender affirmation processes, with significant differences between the three groups in terms of particular experiences. The NB participants also reported significantly lower rates of transgender congruence, specifically lower appearance congruence though similar gender identity acceptance.

Conclusion: The NB transgender adults in this sample report unique identity-related characteristics, including significantly lower rates of medical/social transition as well as decreased transgender congruence. These data are among the first to describe unique pathways by which NB adults, TW, and TM may pursue gender affirmation and interact with providers as they navigate congruence, transition, and well-being.

Perspectives of trans and gender diverse young people accessing primary care and gender-affirming medical services: Findings from Trans Pathways

Background: Increasing numbers of trans young people are seeking medical services worldwide, but there have been few qualitative investigations of the experiences of trans young people attempting to engage with these services to explore in-depth experiences of clinical interactions. Aims: We aimed to explore the experiences of trans young people accessing primary care and gender-affirming medical services in Australia for reasons related to their gender. Methods: Using data from a large mixed methods cross-sectional study, we explored the personal experiences of trans young people aged 14-25 (N = 859) receiving care within primary care services and gender-affirming medical services. Qualitative data on these service experiences were thematically analyzed. Results: Trans young people in Australia reported experiencing difficulties when accessing medical services, especially in relation to gender-affirming medical intervention, referrals to specialist services, and obtaining clinical support in an affordable and timely manner. We found that trans young people were frequently confronted with negative experiences due to clinicians lacking expertise in providing gender-affirming care. Trans young people also reported many positive experiences, including feeling their gender identity was valued and respected by certain services. Although many practitioners attempted to assist their trans patients, they often did not provide satisfactory care and young people were often left to navigate the health care system unsupported. These interactions were often constrained by long waiting times and service cost. Discussion: In general, clinicians require further training to be able to respectfully interact with trans patients and to adequately assist trans young people to obtain necessary medical care. The danger of providing such non-affirmative care to a trans young person is not only invalidating the young person's identity, but also an elevated risk of ill-health due to later avoidance of health care.

Pediatric Research and Health Care for Transgender and Gender Diverse Adolescents and Young Adults: Improving (Biopsychosocial) Health Outcomes

Adolescent and young adult (AYA) transgender health care and research have expanded rapidly in the United States and abroad, but the effects of gender-affirming social, hormonal, or surgical care on overall health remain unclear. Gender diverse identities, also termed nonbinary, have often been neglected in favor of (male/female) binary identities, even in the context of transgender health care and research. No high quality studies have assessed how gender-affirming medical care impact health inequities in transgender and gender diverse (TG/GD) adults, much less in AYAs, despite the fact that that TG/GD adults have higher than average morbidity and mortality across a host of health concerns, from human immunodeficiency virus infection to thromboembolism, and that reported depression with suicidal ideation is >10 times higher in TG/GD adults than in the general population. TG/GD youth have related but different needs from TG/GD adults. TG/GD AYA are embedded in family and schools, where stigma may be difficult to escape; mental health during adolescence has areas of increased risk as well as resilience; and the effects of early hormonal and surgical interventions on long-term health are insufficiently studied. Because of this, an inclusive and proactive approach to addressing the needs of TG/GD AYA by pediatric clinicians, researchers, and educators is particularly crucial. This article focuses on what is known and unknown about clinical practice, research, and education related to TG/GD health. We highlight the role of gender affirmation by clinicians as they care and advocate for TG/GD AYAs; the potential challenges of hormonal treatment for peripubertal youth; and short- and long-term effects on physical and reproductive health of medical or surgical interventions. We also discuss how social context influences knowledge gaps and the health-relevant risks faced by TG/GD AYA. The challenges are formidable, but opportunities await: high priority research questions to explore, educational gaps to be filled, and advocacy that needs the voices of pediatricians to promote policies to facilitate positive health outcomes for TG/GD AYA.

Non-Binary and Binary Gender Identity in Australian Trans and Gender Diverse Individuals

Many trans and gender diverse (TGD) people have gender identities that are not exclusively male or female but instead fall in-between or outside of the gender binary (non-binary). It remains unclear if and how those with non-binary gender identity differ from TGD individuals with binary identities. We aimed to understand the sociodemographic and mental health characteristics of people with non-binary identities compared with binary TGD identities. We performed a retrospective audit of new consultations for gender dysphoria between 2011 and 2016 in three clinical settings in Melbourne, Australia; (1) Equinox Clinic, an adult primary care clinic, (2) an adult endocrine specialist clinic, and (3) the Royal Children's Hospital, a child and adolescent specialist referral clinic. Age (grouped by decade), gender identity, sociodemographic, and mental health conditions were recorded. Of 895 TGD individuals, 128 (14.3%) had a non-binary gender. Proportions differed by clinical setting; 30.4% of people attending the adult primary care clinic, 7.4% attending the adult endocrine specialist clinic, and 8.0% attending the pediatric clinic identified as non-binary. A total of 29% of people in the 21-30-year-old age-group had a non-binary gender identity, higher than all other age-groups. Compared to TGD people with a binary gender identity, non-binary people had lower rates of gender-affirming interventions, and a higher prevalence of depression, anxiety, and illicit drug use. Tailoring clinical services to be inclusive of non-binary people and strategies to support mental health are required. Further research to better understand health needs and guide evidence-based gender-affirming interventions for non-binary people are needed.

One size does not fit all: differential transgender health experiences

Transgender and nonbinary (TNB) adults face a multitude of challenges when attempting to access general health care. Issues include fear of discrimination and encounters with providers who are not familiar with treating the needs of this population. These challenges may result in the delay or denial of medically necessary care. This study explores nuanced experiences of gender identity and sexual orientation around accessing health care. Using a statewide sample of TNB individuals (N = 417), analyses include descriptive statistics and logistic regressions predicting delayed care due to fear of discrimination and having any medical intervention to understand the importance of transgender-inclusive care and other experiences across identities. Findings indicate differential experiences across gender identity, sexual orientation, and age. Access to a trans-inclusive primary care provider was one of the strongest indicators both for not delaying care due to fear of discrimination and having had a medical intervention. Providers should be provided with more nuanced training about being culturally responsive and aware of differences across sexual orientation within the TNB community. This will move toward ensuring not only increased access to needed care and medical interventions, but toward potentially lowering the rate of those who delay access to care due to fear of discrimination.

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.