Health disparities between binary and non binary trans people: A community-driven survey

Exploring Work Absences and Return to Work During Social Transition and Following Gender-Affirming Care, a Mixed-Methods Approach: 'Bridging Support Actors Through Literacy'

PURPOSE

Research on return to work (RTW) following transition-related gender-affirming care (GAC) is lacking. We aim to study the RTW outcomes and experiences of transgender and gender diverse (TGD) people during social and medical transition to understand their needs better and provide tailored support.

METHODS

In this convergent mixed-methods study, the questionnaires of 125 employed TGD people, who took steps in transition (social and GAC), were analyzed for personal- and work characteristics, medical work absences, RTW, support at work, and health literacy. In-depth interviews were held with twenty TGD people to explore perceived facilitators and barriers to RTW.

RESULTS

One hundred and nine participants reported an average of 38 sick days after GAC. The majority (90.2%) resumed their job at the same employer. Although TGD workers felt supported, their health literacy (55.1%) was lower compared to the general population. The qualitative data analysis revealed four major themes: (1) the need and access to information; (2) having multidisciplinary TGD allies; (3) the influence of the occupational position; (4) the precarious balance between work, life, and GAC. Especially participants with a low health literacy level experienced RTW barriers by struggling: (1) to find and/or apply information; (2) to navigate (occupational) health and insurance services.

CONCLUSION

Our research has shown that RTW for TGD individuals is a multifaceted process, affected by personal factors, work-related elements, and the characteristics of the healthcare and social insurance system. Enhancing support for TGD people at work and their RTW requires a high need for centralized information and promoting health literacy while engaging relevant stakeholders, such as prevention services and employers.

Contraception Requirements in Clinical Research Consent Forms: Assessing and Supporting Gender Inclusive Practices

Gender-diverse individuals are underserved in clinical research settings. Reliance on gendered language throughout the consent process for clinical research contributes to the marginalization of these populations. The research objective was to assess use of gender-inclusive language used to describe the contraception requirement in consent forms. We categorized and analyzed contraception language in 289 clinical trial consent forms using a deductive and summative content analysis approach. We found that 79% (n = 227) of consent forms contained gender-inclusive language, 80% (n = 231) used terms that fell under the biological sex language, and 91% (n = 264) used gendered language. No consent forms used exclusively gender-inclusive language and the majority 63% (n = 182) featuring a combination of all three language types. There were many consent forms which would have been entirely gender-inclusive language if section headings with references to biological-sex-specific contraceptives were excluded, suggesting that gender-inclusive language may be attainable with minor revisions.

A qualitative exploration of gynaecological healthcare experiences of lesbian, gay, bisexual, transgender, queer people assigned female at birth

BACKGROUND

Lesbian, gay, bisexual, transgender, queer, asexual/aromantic (LGBTQA+) people, assigned female at birth (AFAB), experience disproportionately poorer gynaecological healthcare outcomes compared to their cisgender, heterosexual peers. The barriers to gynaecological care remain poorly understood. In a step toward bridging this gap, the current study explored the lived gynaecological healthcare experiences of Australian LGBTQA+ AFAB people and the barriers they experience in accessing care.

MATERIALS AND METHODS

Semi-structured interviews were conducted with 22 LGBTQA+ AFAB people. An inductive thematic qualitative design was used to explore the lived experiences and identify themes associated with the reported experiences.

RESULTS

Thematic analysis identified seven themes related to experiences in accessing gynaecological healthcare, including discrimination, fear, perceived provider or cultural incompetency, accessibility, and gender identity. Several sub-themes were also identified such as refusal of care, microaggression, misgendering, and patient as educator.

CONCLUSIONS

Participants suggested that barriers to care could be alleviated by the integration of LGBTQA+ specific healthcare training into the university-level medical curriculum and professional development programs that address cultural competency and inclusive healthcare. These preliminary findings inform the necessity for the development of evidence-based practice guidelines that specifically address the unique and diverse needs of the LGBTQA+ AFAB population.

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.

Life Satisfaction and Negative Affect Among Trans Men, Trans Women, and Nonbinary Individuals in a U.S. National Sample

Purpose: Transgender and nonbinary individuals often have limited educational and economic resources, lack social capital such as family and community support, and face discrimination. These factors are likely to have negative consequences for subjective well-being of transgender individuals. Yet, there is limited research using a national sample and comparing trans women, trans men, and nonbinary individuals. This study examined the impact of social support, social belonging, transgender connectedness, and discrimination on trans and nonbinary individuals' life satisfaction and negative affect. Methods: We used data from TransPop 2016-2018, the first survey conducted on a national probability sample of the transgender population in the United States. We focused on measures of life satisfaction and negative affect and their predictors, including social belonging, transgender connectedness, and everyday discrimination. Results: We found that trans men, trans women, and nonbinary individuals had lower life satisfaction and higher negative affect than cisgender heterosexual individuals. Social belonging had a positive effect on trans men and trans women's life satisfaction, whereas it had a negative effect on trans men and nonbinary individuals' negative emotion. While family support had a positive effect on trans men's life satisfaction, social support had mixed effects on nonbinary individuals' life satisfaction and negative affect. Finally, everyday discrimination had a negative influence on life satisfaction although there was variation by gender identity and dependent measure. Conclusion: Different factors predicted life satisfaction and negative affect of trans men, trans women, and nonbinary people. Thus, a one-size-fits-all model of trans and nonbinary subjective well-being does not work.

Voices from a Multidisciplinary Healthcare Center: Understanding Barriers in Gender-Affirming Care-A Qualitative Exploration

When seeking gender-affirming care, trans* and gender-diverse individuals often describe experiencing barriers. However, a deeper understanding of what constitutes such barriers is generally lacking. The present research sought to better understand the barriers trans* and gender-diverse individuals experienced, and their effects, when seeking gender-affirming care in the Netherlands. Qualitative interviews were conducted with trans* and gender-diverse individuals who sought care at a Dutch multidisciplinary medical center. Twenty-one participants were included, of which 12 identified as (trans) male, six identified as (trans) female, one as trans*, and one as gender-nonconforming (GNC)/non-binary. The interviews were mostly conducted at the homes of the participants and lasted between 55 min and 156 min (mean = 85 min). Following data collection and transcription, the interviews were analyzed using axial coding and thematic analysis. A total of 1361 codes were extracted, which could be classified into four themes describing barriers: lack of continuity: organizational and institutional factors (n_codes = 546), patient-staff dynamics (n_codes = 480), inadequate information and support (n_codes = 210), and lack of autonomy in decision making (n_codes = 125). Within our study, trans* and gender-diverse individuals described encountering multiple and diverse barriers when seeking gender-affirming care in the Netherlands. Future studies are needed to evaluate whether individualized care, the decentralization of care, and the use of decision aids can improve the experienced barriers of trans* and gender-diverse individuals seeking gender-affirming care within the Dutch healthcare system.

What Category Best Fits: Understanding Transgender Identity in a Survey of Autistic Individuals

Introduction

Calls for improved measures of gender identity to understand the experience of transgender individuals have grown rapidly in the past 5 years. The need for methodological innovation in this topic area has particular importance for the autistic population since a higher co-occurrence of transgender identities among autistic people has been documented but is not well understood. We use a survey with questions that reflect standards in 2018 to demonstrate how binary conceptualizations of gender did not adequately capture gender identities of transgender autistic individuals.

Methods

Using descriptive statistics from a statewide survey of 1527 autistic adults (mean age 27.5 years), this study compared self-reported survey responses to close-ended standard questions at the time about gender identity to understand shortcomings in capturing this population authentically.

Results

We found a mismatch between respondents answering that they were transgender, the sex assigned at birth, and gender identity on separate questions. We postulate that transgender men and women were likely selecting binary responses when asked about gender identity. Furthermore, we found that many qualitative responses reported in the self-selected "other" category reflected nonbinary identities and utilized specific terminology that revealed nuance in how they understood gender identities.

Conclusions

We urge researchers to provide multiple flexible options when measuring gender identity in autistic populations as they are likely to encompass many identities. We endorse best practices for measuring gender identity for autistic research.

Santé des personnes non binaires : de quoi parle-t-on ?

Through quantitative research on the health of LGBT people (2018) and alongside a review of the literature on the health of non-binary people, this article aims to revisit the specific health characteristics of this population.

Implementation of a Risk Reduction Protocol in Youth Violence Research

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

Non-Binary 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.

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.

Gender Diverse Representation in Patient Simulation: A Scoping Review

PURPOSE

Despite recent advocacy for transgender and nonbinary (TGNB) health competencies in medical education, there is little guidance on how to represent diverse gender identities for clinical skills training. Published literature is one of few resources available to inform educators' decisions, so this study aims to summarize how medical education scholarship portrays TGNB identities in patient simulation.

METHOD

This scoping review used PRISMA guidelines with search strings encompassing diverse gender identities and patient simulation. This search was completed in July 2021, and all years of publication were included. The authors completed a 3-tiered review to identify relevant studies and then extracted data to summarize how TGNB patients were portrayed and training outcomes.

RESULTS

After screening 194 total articles, 44 studies met the criteria for full review. Of these, 22 studies involved TGNB simulated patient cases. Within these, 15 (68%) reported the specific gender identities represented in the patient case, revealing mostly binary transgender identities. Sixteen studies (73%) reported the gender identities of all actors who portrayed the patient. The identities of all patients and actors matched in only 10 articles (45%), indicating that most programs portray TGNB identities with cisgender or unspecified standardized patients. Nearly all studies reported desirable learner outcomes. Several noted the advantage of authenticity in recruiting TGNB actors and the need to achieve more accurate representation of TGNB patients.

CONCLUSIONS

Educators are increasingly representing TGNB identities in clinical skills training. These results show a lack of nonbinary representation and discrepancies between TGNB patient cases and standardized patient identities. These data also suggest that simulation programs need and desire better recruitment strategies within TGNB communities. Because TGNB communities are not a monolith, reporting out and analyzing gender identities of simulation cases and people hired to portray TGNB patients helps ensure that TGNB care is taught effectively and respectfully.

Improving menstrual equity in the USA: perspectives from trans and non-binary people assigned female at birth and health care providers

Menstruation research has largely focused on addressing menstrual management barriers facing cisgender women and girls in low and middle-income countries. Scant literature has assessed the menstrual management needs of trans and non-binary people assigned female at birth. To better understand these frequently invisibilised menstruation-related needs, we conducted a multi-method qualitative study in New York City which included: 17 in-depth interviews across trans and non-binary people (n = 10) and health care providers who serve them (n = 7); and seven anonymous post-interview participatory writing responses with trans and non-binary participants to further elucidate their lived experiences with menstrual management. Lack of health care provider transgender competency, public toilet design (i.e. gaps in cubicle doors and lack of in-cubicle menstrual product disposal bins), and the social dynamics of public toilets (i.e. work and school) were identified as significant barriers to managing menstruation safely and accessibly for trans and non-binary people. These findings have important implications for healthcare policy, public toilet legislation and advancing menstrual equity in the USA.

Interdisciplinary clinicians' attitudes, challenges, and success strategies in providing care to transgender people: a qualitative descriptive study

BACKGROUND

Access to clinicians competent in transgender health remains a significant barrier and contributor toward health inequity for transgender people. Studies on access and barriers to care have predominantly evaluated transgender patients' perceptions, but scant research has included the perspectives of clinicians.

AIMS

We conducted a qualitative study to explore how clinicians (meaning physicians and advanced practice providers, in this paper) in the United States: (1) attain and utilize information, (2) perceive barriers and facilitators, and (3) understood gaps in their professional training, in regard to practicing transgender health care.

METHODS

A Qualitative Descriptive approach guided our conventional content analysis of field notes and interviews with clinicians within a parent study that explored health care access among transgender adults. Transcripts were coded into meaning units that were iteratively abstracted into themes. Standard measures were performed to promote the trustworthiness of the analysis and reduce bias.

RESULTS

Participants (n = 13) consisted of physicians (n = 8), physician assistants (n = 3), and nurse practitioners (n = 2). The majority were women (n = 11), identified as White (n = 9), cisgender (n = 13), and ages ranged from 31 - 58 years. Five main themes were identified: (1) Knowledge Acquisition: Formal and Informal Pathways to Competency; (2) Perceived Challenges and Barriers: I didn't know what I was doing; (3) Power to Deny: Prescriptive Authority and Gatekeeping; (4) Stigma: This is really strange, and I can't really understand it; (5) Reflections: Strategies for Success, Rewards, and Personal Motivations.

DISCUSSION

Clinicians gained a sense of comfort and competence with mentorship, self-directed learning, clinical experience, and person-centered, harm-reduction approaches. Stigma, bias, and structural-level factors were barriers to providing care. This study offers a unique perspective of clinicians' motivations and strategies for providing gender-affirming care and elucidates how stigma impacts the delivery of gender-affirming care.

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.

Assigned-Female-at-Birth Trans Masculine and Non-Binary Individuals Differ in Their Body Satisfaction and Desire for Gender Affirming Treatments

Many non-binary individuals physically affirm their gender, but the binary/non-binary component of gender identity is rarely reported, and when it is, assigned-male- and assigned-female-at-birth individuals are often grouped together. We compared the experience of assigned-female-at-birth trans masculine and non-binary individuals via an anonymous online survey and found that patterns of overall body satisfaction and strength of intention to modify the body support the idea that the lower engagement in physical affirmation by non-binary individuals reflects less need to undergo body modifications. Trans masculine and non-binary participants who had had at least one gender affirming treatment (GAT) mostly identified as trans and expressed a similar ranking of GAT preferences. In contrast, non-physically affirmed cohorts differed in strength of intention to modify their body, desired GAT and the proportion who identified as trans, with more than a third of non-physically affirmed non-binary individuals not wanting any GAT and a third wanting GAT without testosterone. Several participants who did not want testosterone used female-based identifiers suggesting that some non-binary individuals use GAT to defeminize rather than masculinize their bodies. Individuals' orientation to the binary/non-binary and trans/non-trans dimensions of identity appears connected to their strength of motivation to physically affirm and their preferred outcomes but there is ambiguity in the usage of the terms. We need to explore what these terms mean to a given individual if we are to support them as they make decisions about whether and how to modify their body to affirm their gender.

Mental health in people with minority sexual orientations: A meta-analysis of population-based studies

AIMS

To conduct a meta-analysis of population-based studies to quantify the association between sexual minority status (lesbian women, gay men, and bisexual people) and the risk of common mental disorders (depressive disorders, alcohol use disorders (AUD), anxiety disorders, and suicidality).

METHOD

PubMed, PsycInfo, Web of Science, the Cochrane Library Database, the Applied Social Sciences Index and Abstracts, and ProQuest were searched for relevant studies published between 2000 and May 2020. The PRISMA guidelines were followed for selection processes. Twenty-six studies met the inclusion criteria which included a total of 519,414 heterosexuals, 10,178 lesbian/gay people and 14,410 bisexual people.

RESULTS

Lesbian/gay people (ORs between 1.97, 95% [CI = 1.76, 2.19] and 2.89, 95% [CI = 2.41,3.38]) and bisexual people (ORs between 2.70; 95% [CI = 2.21,3.18], and 4.81; 95% [CI = 3.63, 5.99]) had a higher risk for mental disorders than heterosexuals for all investigated diagnostic categories. The risk for depression (OR = 2.70; 95% [CI = 2.21, 3.18]) and suicidality (OR = 4.81; 95% [CI = 3.63, 5.99]) was higher in bisexual compared with lesbian/gay people. Exploratory meta-regressions revealed no evidence for a decrease in mental health differences between people with minority sexual orientations and heterosexuals in more recent years of data assessment, except for AUD.

CONCLUSIONS

These findings clearly suggest disparities in mental health between people with minority sexual orientations and heterosexual people. There is a lack of data regarding a wider spectrum of sexual orientations and mental disorders and studies in non-Western countries.

Interdisciplinary, internet-based trans health care (i²TransHealth): study protocol for a randomised controlled trial

INTRODUCTION

Living in an area with no or deficient structures for trans health care is disadvantageous for trans people. By providing an internet-based health care programme, i²TransHealth aims at reducing structural disadvantages for trans people living in areas lacking specialised care. The e-health intervention consists of video consultations and a 1:1 chat with a study therapist. Additionally, the i²TransHealth network cooperates with physicians, who especially offer crisis intervention close to the participants' place of residence. The aim of this study is to evaluate the (cost-)effectiveness of the internet-based health care programme for trans people compared with a control (waiting) group. The following research questions will be examined with a sample of 163 trans people: Does a 4-month treatment with the i²TransHealth internet-based health care programme improve patient-reported health-outcomes? Is i²TransHealth cost-effective compared with standard care from a societal or health care payers' perspective? Does the participation in and support by i²TransHealth lead to an increase of trans-related expertise in the physician network?

METHODS AND ANALYSIS

In a randomised controlled trial, the outcomes of an internet-based health care programme for trans people will be investigated. In the intervention group, participants are invited to use i²TransHealth for 4 months. Participants allocated to the control group will be able to start with their transition-related care after 4 months of study participation. The primary outcome measure is defined as the reduction of psychosomatic symptoms, as assessed by the Brief Symptom Inventory-18, 4 months after using the i²TransHealth programme. Participants in both groups will undergo an assessment at baseline and 4 months after using i²TransHealth.

ETHICS AND DISSEMINATION

Positive ethical approval was obtained from the Hamburg Medical Association (PV7131). The results will be disseminated to service users and their families via media, to health care professionals via professional training and meetings and to researchers via conferences and publications.

TRIAL REGISTRATION NUMBER

NCT04290286.

PROTOCOL VERSION

22 December 2021 (V.1.0).

Operationalizing and analyzing 2-step gender identity questions: Methodological and ethical considerations

OBJECTIVE

Two-step questions to assess gender identity are recommended for optimizing care delivery for gender-diverse individuals. As gender identity fields are increasingly integrated into electronic health records, guidance is needed on how to analyze these data. The goal of this study was to assess potential approaches for analyzing 2-step gender identity questions and the impact of each on suicidal ideation.

MATERIALS AND METHODS

A regional Youth Risk Behavior Survey in one Northeastern school district used a 2-step question to assess gender identity. Three gender measurement strategies (GMSs) were used to operationalize gender identity, (1) combining all gender-diverse youth (GDY) into one category, (2) grouping GDY based on sex assigned at birth, and (3) categorizing GDY based on binary and nonbinary identities. Mixed-effects logistic regression was used to compare odds of suicidal ideation between gender identity categories for each GMS.

RESULTS

Of the 3010 participants, 8.3% were GDY. Subcategories of GDY had significantly higher odds (odds ratio range, 1.6-2.9) of suicidal ideation than cisgender girls regardless of GMS, while every category of GDY had significantly higher odds (odds ratio range, 2.1-5.0) of suicidal ideation than cisgender boys.

CONCLUSIONS

The field of clinical informatics has an opportunity to incorporate inclusive items like the 2-step gender identity question into electronic health records to optimize care and strengthen clinical research. Analysis of the 2-step gender identity question impacts study results and interpretation. Attention to how data about GDY are captured will support for more nuanced, tailored analyses that better reflect unique experiences within this population.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

DISCUSSION

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

How the COVID-19 pandemic affects transgender health care - A cross-sectional online survey in 63 upper-middle-income and high-income countries

Background

Due to the COVID-19 pandemic, access to medical care is restricted for nearly all non-acute conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments, transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic.

Methods

As an ad hoc collaboration between researchers, clinicians and 23 community organizations, we developed a web-based survey in German that was translated into 26 languages. Participants were recruited via community sources, social media channels, and snowball sampling since May 2020. The present sample is based on the data collected until August 9, 2020. We assessed demographical data, health problems, risk factors, COVID-19 data (e.g., contact history), and the influence of the COVID-19 pandemic on access to transgender health care services. To identify factors associated with the experience of restrictions, we conducted multiple logistic regression analysis.

Results

5267 transgender people from 63 upper-middle-income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding COVID-19 treatment due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% reported at least one mental health condition and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic.

Discussion

Transgender people suffer under the severity of the pandemic due to the intersections between their status as a vulnerable social group, their high number of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender people, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behavior, and suicidality.

Socioeconomic status in Danish transgender persons: a nationwide register-based cohort study

BACKGROUND

Gender dysphoria could be associated with low socioeconomic status (SES). SES could be modified by age, ethnic background, and medical morbidity.

AIM

To determine SES in a national study population including transgender persons in Denmark.

METHODS

National register-based cohort study in Danish transgender persons and age-matched controls. The transgender study cohort included persons with ICD-10 diagnosis code of 'gender identity disorder' and/or persons with legal sex change and persons who fulfiled the inclusion criteria during 2000-2018. The main outcome measure was SES including personal income, occupational status, and education.

RESULTS

The cohort included 2770 transgender persons and 27,700 controls. In the transgender study cohort, 1437 were assigned male at birth (AMAB), median age (interquartile range, IQR) 26.0 (17.3) years, and 1333 were assigned female at birth (AFAB), median age 22.5 (10.3) years. Adjusting for age and sex, the relative risk ratio (RRR) of low vs high personal income was 5.6 (95% CI: 4.9; 6.3) in transgender persons compared to controls. The RRR of low vs high income was 6.9 (5.8; 8.3) in persons AMAB compared to control males and 4.7 (3.9; 5.6) in persons AFAB compared to control females. The RRR of low vs high income was 3.7 (3.2; 4.3) in transgender persons of Danish origin compared to controls. The Charlson comorbidity index was comparable in transgender persons vs controls.

CONCLUSIONS

Being transgender was negatively associated with SES. In transgender persons, the risk of low vs high income could be more pronounced in transgender persons of foreign origin.

Experienced barriers of care within European treatment seeking transgender individuals: A multicenter ENIGI follow-up study

Objectives: To evaluate the experienced barriers of care for treatment-seeking trans individuals (TSTG) in three large European clinics. Methods: An online follow-up questionnaire was filled out by 307 TSTG individuals as part of the research protocol of the European Network for the Investigation of Gender Incongruence (ENIGI). Data was collected during follow-up in 2017/2018, around 5 years after participants had their initial clinical appointments in Ghent (Belgium), Amsterdam (the Netherlands), or Hamburg (Germany). Background characteristics, country, treatment characteristics and mental health were analyzed in relation to experienced barriers of care (EBOC, measured though agreement with statements). Results: The majority of participants reported various EBOC, oftentimes more than one. The most-frequently reported EBOCs pertained to the lack of family and friends' support (28.7%, n = 88) and travel time and costs (27.7%, n = 85), whereas around one-fifth felt hindered by treatment protocols. Also, a significant share expressed the feeling that they had to convince their provider they needed care and/or express their wish in such way to increase their likelihood of receiving care. A higher number of EBOCs reported was associated with more mental health problems, lower income and female gender. Conclusions: A substantial number of TSTG individuals within three European health care systems experiences EBOCs. EBOCs relate to both personal and systemic characteristics. These findings can help health care providers and centers to improve care. More research must be done to better understand the diversity among TSTG individuals and the corresponding barriers experienced. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1964409.

Systemic inflammation as a driver of health disparities among sexually-diverse and gender-diverse individuals

Sexually-diverse individuals (those who seek sexual or romantic relationships with the same and/or multiple genders) and gender-diverse individuals (those whose gender identity and/or expression differs from their birth-assigned sex/gender) have disproportionately high physical health problems, but the underlying biological causes for these health disparities remain unclear. Building on the minority stress model linking social stigmatization to health outcomes, we argue that systemic inflammation (the body's primary response to both physical and psychological threats, indicated by inflammatory markers such as C-reactive protein and proinflammatory cytokines) is a primary biobehavioral pathway linking sexual and gender stigma to physical health outcomes. Expectations and experiences of social threat (i.e., rejection, shame, and isolation) are widespread and chronic among sexually-diverse and gender-diverse individuals, and social threats are particularly potent drivers of inflammation. We review research suggesting that framing "minority stress" in terms of social safety versus threat, and attending specifically to the inflammatory consequences of these experiences, can advance our understanding of the biobehavioral consequences of sexual and gender stigma and can promote the development of health promoting interventions for this population.

Exploring Health and Transition-Related Needs in Polish Transgender and Non-Binary Individuals

BACKGROUND

Gender diverse individuals constitute a substantial yet still understudied population. Particularly little is known about gender non-binary people whose health needs have only recently gained attention from clinicians.

AIM

To investigate needs for gender-affirming interventions, selected health indicators and determinants in Polish gender non-binary individuals as compared to transgender men and transgender women.

METHODS

We analyzed a subset of data from an online study on health in members of the Polish LGBTQ community. The sample consisted of 53 persons who self-identified as non-binary and 45 transgender men and transgender women. The uptake and the desire for gender-affirming medical interventions as well as selected health indicators were compared in non-binary and transgender persons. Additionally, regression models were conducted for depression, self-esteem and somatic symptoms severity as dependent variables, age as a covariate, and perceived stigma exposure, resilience and discomfort associated with current gender expression as predictors.

OUTCOMES

Outcomes such as desire for gender-affirming medical interventions and legal gender reassignment, symptoms of depression, resilience, physical symptoms severity, and perceived stigma exposure were captured in self-reported questionnaires.

RESULTS

Compared to the transgender men and transgender women, the non-binary participants of the study significantly less often pursued or desired gender-affirming medical interventions and legal gender reassignment. The non-binary participants also felt significantly more discomfort with their current gender expression. They were also characterized by increased expectations of rejection, vicarious trauma associated with being an LGBTQ person, and by decreased resilience compared to the transgender men and transgender women. Non-binary identity and individual resilience predicted higher self-esteem and decreased depression in the sample. The severity of physical symptoms was predicted by perceived stigma exposure (positively) and by resilience (negatively).

CLINICAL IMPLICATIONS

Polish non-binary individuals may constitute a vulnerable population in terms of greater perceived exposure to stigma and decreased individual resilience. Both transgender and non-binary individuals seek gender-affirming interventions and legal gender reassignment; the latter group, however, does so significantly less often.

STRENGTHS & LIMITATIONS

We analyzed the data from a unique and understudied Polish population. By exploring the diversity within the transgender and non-binary community, we add to the ongoing discussion on transgender and non-binary health. The major limitations of the study are convenience sampling, cross-sectional design, and limited sample size.

CONCLUSION

Non-binary individuals constitute a distinct population in terms of psychosocial and health-related characteristics. Clinicians should be aware of their needs and the challenges they face in association with living in a predominantly gender binary-oriented society. Koziara K, Mijas M. Wycisk J, et al. Exploring Health and Transition-Related Needs in Polish Transgender and Non-Binary Individuals. J Sex Med 2021;18:1110-1121.

Alleviating gender dysphoria: A qualitative study of perspectives of trans and gender diverse people

OBJECTIVES

This study sought to explore perspectives of trans and gender diverse (TGD) people of ways to alleviate gender dysphoria in service provision and to develop a framework for application in health and other areas that can be used by researchers and service providers to design study protocols, assess organisations and enhance everyday practice in ways that are sensitive to TGD people's experiences.

METHODS

Data from a national Australian survey on TGD people conducted in 2018-2019 (n = 340) were used to develop a framework for alleviating dysphoria. Participants were asked an open-ended question on ways that body discomfort could be minimised in clinical encounters. Inductive thematic analysis was used to develop themes true to participant sentiment, which formed the basis for the development of a framework.

RESULTS

The sample was overall young, with 60.6% aged 18-24, and a strong representation of gender diverse people (42.6%). The most important theme for participants was the context of the experience, which included the subthemes of the interpersonal qualities of service providers, language and pronouns, and practical aspects. Aspects of systems were also important, with education and awareness being particularly emphasised, followed by inclusive environments. Access to gender affirming medical and surgical procedures was rarely mentioned (2.6%). A minority of participants indicated that there was nothing that could be done to alleviate their gender dysphoria (4.4%).

CONCLUSIONS

The study proposes a framework that can help facilitate assessment of a service's current practices, inform a practitioner's daily practice and be used by researchers to appropriately design studies. The most important areas to address centre on the context of the immediate experience, which may be influenced through systems-level characteristics.

Trans and gender diverse people's experiences and evaluations with general and trans-specific healthcare services: a cross-sectional survey

Research into access to and experiences with healthcare services of gender-diverse and trans individuals remains scarce. In this paper, self-reported experiences with general and trans-specific healthcare services were analyzed for differences between gender-diverse people, trans men, and trans women, using data from a five-country survey. More than half of all respondents indicated they had delayed general healthcare services at least once because of their gender identity, mostly out of fear of being treated badly. Almost one in four participants felt personally discriminated against in general healthcare services within the previous year. Gender-diverse people had significantly less experiences with seeking trans-specific healthcare. Additional effects were found for different socio-demographic variables (age; sex assigned at birth; educational level; socioeconomic status; and belonging to an ethnic, sexual, and/or disability minority). Gender-diverse people gave significantly worse evaluations of trans-specific healthcare services (in general as well as for specific types of trans-specific healthcare). The findings highlight the need for healthcare providers in creating inclusive healthcare settings, with attention for gender-diverse clients and those belonging to precarious minority groups due to their level of education or sexual, disability, and/or ethnic background.

Clinically and Culturally Competent Care for Transgender and Nonbinary People: A Challenge to Providers of Perinatal Care

Transgender and nonbinary people experience high rates of discrimination and stigma in healthcare settings, which have a deleterious effect on their health and well-being. While the preventative healthcare needs of transgender and gender nonbinary people are slowly starting to make their way into nursing curriculum, there is still a very little guidance on how to appropriately and respectfully care for this population during one of the most vulnerable interactions with the healthcare system, the perinatal period. Without exposure or education, nurses are challenged on how to provide compassionate and culturally competent care to transgender and nonbinary people. The focus of this review is to provide guidance to nurses caring for transgender and gender nonbinary people during the perinatal period. Terminology and respectful language, a discussion around the decision to parent, affirming approaches to physical examination, and care during pregnancy and the postpartum period are all discussed. By increasing the number of nurses who are trained to deliver high-quality and affirming care to transgender and nonbinary patients, challenging health inequities associated with provider discrimination can be mitigated.

The myth of 'older LGBT+' people: Research shortcomings and policy/practice implications for health/care provision

This article explores the implications of research which takes a collectivised approach to lesbian, gay, bisexual and trans+ (LGBT+) ageing and which engages in Questionable Research Practices (QRPs) in doing so. Collectivised approaches to heterogenous identity-based groups address commonalities but often fail to address internal diversity, i.e. the differences between and among older LGBT+ people. This article explores six key problems associated with collectivised research: (1) Homogenising language and phrases; (2) Uneven numerical representation of sub-groups; (3) Thematic over-representation of sexuality; (4) Non-intersectional analyses; (5) Thematic under-representation of gender; and (6) Inaccurate reporting of data. Research which does not differentiate between 'older LGBT+' sub-populations, can provide policy-makers and practitioners with inaccurate and/or misleading information, resulting in services which meet the needs of some, but not all, older LGBT+ people. This article discusses how research can become more inclusive, intersectional and reliable.

Health Disparities Among Sexual and Gender Minorities with Autism Spectrum Disorder

We explored the health and health care experiences of people with autism spectrum disorder (ASD) who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ+) using data from a national, internet-based survey of adults with disabilities supplemented by focused interviews. LGBTQ+ respondents had significantly higher rates of mental illness, poor physical health days per month, and smoking compared to straight, cisgender respondents with ASD. LGBTQ+ respondents also reported much higher rates of unmet health care need, inadequate insurance provider networks, and rates of being refused services by a medical provider. Examining the intersection of LGBTQ+ identity and ASD reveals compounded health disparities that insurers and medical providers are not adequately addressing, particularly as individuals transition to the adult medical system.

Intersecting Experiences of Healthcare Denials Among Transgender and Nonbinary Patients

INTRODUCTION

Transgender and nonbinary individuals experience high levels of health disparities and are more likely to experience denials of health care than their cisgender (nontransgender) counterparts. There is a lack of evidence on how healthcare denials vary by gender identity and other intersecting identity characteristics in the transgender and nonbinary populations.

METHODS

Using data from the 2015 U.S. Trans Survey (n=27,715), multivariate logistic regressions were used to analyze (in 2019) the increased likelihood of experiencing denials of trans-related care and standard care across socioeconomic and identity characteristics among the transgender and nonbinary population, including race, age, educational attainment, disability, income, and gender identity.

RESULTS

Almost 8% of the participants had been denied trans-specific health care, and >3% had been refused general health care. Transgender (compared with nonbinary), older, biracial, or multiracial, and lower-income participants, as well as those with less than a high school diploma and those with disabilities, were significantly more likely to experience refusal of care in general or trans-specific healthcare settings.

CONCLUSIONS

There is a need for better training of healthcare providers to be inclusive and reduce denial rates of their transgender and nonbinary patients. However, it is also clear that current rates of denial must be considered through a whole-person lens, considering the experience of concurrent oppressed identities and recognizing the increased risk those with multiple marginalized identities experience in being denied needed health care.