Depathologising gender diversity in childhood in the process of ICD revision and reform

Building a Cohort of Transgender and Nonbinary Patients from the Electronic Medical Record

Purpose: Sexual orientation, gender identity, and sex recorded at birth (SOGI) have been routinely excluded from demographic data collection tools, including in electronic medical record (EMR) systems. We assessed the ability of adding structured SOGI data capture to improve identification of transgender and nonbinary (TGNB) patients compared to using only International Classification of Diseases (ICD) codes and text mining and comment on the ethics of these cohort formation methods. Methods: We conducted a retrospective chart review to classify patient gender at a single institution using ICD-10 codes, structured SOGI data, and text mining for patients presenting for care between March 2019 and February 2021. We report each method's overall and segmental positive predictive value (PPV). Results: We queried 1,530,154 EMRs from our institution. Overall, 154,712 contained relevant ICD-10 diagnosis codes, SOGI data fields, or text mining terms; 2964 were manually reviewed. This multipronged approach identified a final 1685 TGNB patient cohort. The initial PPV was 56.8%, with ICD-10 codes, SOGI data, and text mining having PPV of 99.2%, 47.9%, and 62.2%, respectively. Conclusion: This is one of the first studies to use a combination of structured data capture with keyword terms and ICD codes to identify TGNB patients. Our approach revealed that although structured SOGI documentation was <10% in our health system, 1343/1685 (79.7%) of TGNB patients were identified using this method. We recommend that health systems promote patient EMR documentation of SOGI to improve health and wellness among TGNB populations, while centering patient privacy.

Telemedicine Utilization Among Transgender and Gender-Diverse Adolescents Before and After the COVID-19 Pandemic

Introduction: Little is known about how expansion of telemedicine services during the COVID-19 pandemic has affected access to gender-affirming care for transgender and gender-diverse (TGD) youth. The purpose of this study was to explore differences in demographic characteristics and visit completion rates at a multidisciplinary gender clinic before and after telemedicine implementation in March 2020 and among telemedicine users and nonusers. Methods: Data were from electronic health records of Seattle Children's Gender Clinic (SCGC) patients seen between April 2019 and February 2021. We assessed differences in demographic characteristics and care utilization (i.e., encounter type and status) between April 2019 and February 2020 (pre-telemedicine) and April 2020 and February 2021 (post-telemedicine). Results: Of the 1,051 unique patients seen at SCGC during this time period, majority groups were as follows: 62% identified as transmasculine/male, 68% were non-Hispanic White, and 76% resided within 50 miles of the clinic. Statistically significant differences were observed in patient pronouns and insurance type when comparing the pre- and post-telemedicine periods (p < 0.01). Half (52%) of post-telemedicine period encounters were conducted through telemedicine, and telemedicine encounters were significantly more likely to be completed (72% vs. 50%) and less likely to be canceled (21% vs. 46%) compared with in-person encounters. Conclusions: Telemedicine services facilitated continued access to gender-affirming care services for TGD youth during the COVID-19 pandemic. Although the introduction of telemedicine did not exacerbate demographic disparities in access to this care, further research and interventions are warranted to address the ongoing disparities in access to gender-affirming care for youth of color and rural youth.

Envisioning a future for transgender and gender-diverse people beyond the DSM

This editorial describes current considerations regarding psychiatric diagnoses for transgender and gender-diverse (TGD) people. In addition to offering an assessment of the limitations in current diagnostic standards, the authors articulate a vision for psychiatric practice marked by renewed commitment to an affirmative framework that reduces stigma.

'A little bubble of utopia': constructions of a primary care-based pilot clinic providing gender affirming hormone therapy

The provision of gender affirming hormone therapy for transgender and non-binary people is a rapidly developing area of gender affirming healthcare. While research indicates the benefits of providing gender affirming hormone therapy through interdisciplinary primary care-based models, less is known about how service users and providers construct their understandings of affirmative approaches. In this paper, we present findings from a discourse analysis of four service users' and four healthcare professionals' talk about a primary care-based pilot clinic providing gender affirming hormone therapy in Aotearoa New Zealand. Participants employed notions of pathologisation, time, and agency in their talk to construct the clinic as a personal setting which gave service users time to make their own health decisions, while constructing hospitals as impersonal with lengthy wait times. The assessment-driven nature of best practice guidelines that governed clinicians' decision-making was constructed as constraining users' agency. Findings highlight the ongoing importance of aligning gender affirming hormone therapy with other non-disease types of healthcare, and suggest new ways for achieving this through affirmative approaches to healthcare.

Transphobic Violence in Educational Centers: Risk Factors and Consequences in the Victims’ Wellbeing and Health

School violence and bullying re worrying problems due to their growing prevalence and severe consequences for adolescent and youth health and wellbeing. Sociocultural factors can contribute to, complicate, and increase the cases of violence in classrooms and spaces related to educational centers. Transphobic violence in this article is defined as the type of violence suffered by transgender and nonbinary adolescents and youth as a manifestation of the problem of discrimination and hate against gender and sexual diversity. This work intends to study the complex sociocultural dynamics of violence detected in educational contexts affecting transgender and nonbinary adolescents and youth identified by recent high- impact studies. At the same time, we aim to fill the gap in the scientific literature on transphobic violence and articulate successful strategies to prevent and combat it. In this review, transphobic violence is defined as the violence affecting transgender adolescents and youth, continuous in time, influenced by peers, and taking place in spaces or realities related to educational centers. The reviewed studies point at the complexity of this kind of violence due to the combination of socio-personal factors and its variety in manifestations. Furthermore, we study the consequences of transphobic violence for the wellbeing and health of transgender and nonbinary adolescents and youth to deepen the knowledge of their mental health repercussions. We end by providing suggestions for how this problem can be prevented in educational environments, grounded on scientific evidence in the materialization of a transformative approach.

[The trans depathologization perspective: a contribution to public health approaches and clinical practices in mental health? SESPAS Report 2020]

Over the last decade, the academic-activist trans depathologization perspective has contributed to a change in the conceptualization of gender transition processes. Observing an interrelation between psychiatrization and transphobic violence, trans depathologization activist groups and allies demand the removal of the diagnostic classification of transexuality as a mental disorder. Furthermore, they have developed trans health care models and legal gender recognition processes based on depathologization and human rights perspectives. They propose changing the role of mental health professionals in trans health care, substituting the psychiatric assessment role by accompaniment and psychological support tasks. The trans depathologization perspective can be related to various approaches and topics relevant in public health and mental health, among them sociology of diagnosis, human rights based approaches to health, human rights protection in mental health, universal health coverage, review of diagnostic classifications, intersectionality perspectives, reflections on bioethical principles, models of integrated people-centered health services and approaches to research ethics. Over the last few years, informed decision-making models have been developed for trans health care in several countries and world regions. Health professionals, including mental health professionals, as well as professionals from the educational and judicial-administrative sector, can have an important role in addressing situations of discrimination and transphobic violence, contributing to the construction of a society that respects, recognizes and celebrates gender diversity.

Trans health care from a depathologization and human rights perspective

Trans people are exposed to multiple human right violations in clinical practice and research. From 1975 on, gender transition processes have been classified as a mental disorder in diagnostic classification manuals, a classification that was removed recently from ICD, International Classification of Diseases, and continues in DSM, Diagnostic and Statistical Manual of Mental Disorders. Trans people in different world regions are forced to accept psychiatric diagnoses and assessment in order to get access to trans health care, subject to reparative therapies and exposed to transphobic institutional and social discrimination and violence. In many countries, gender identity laws include medical requirements, such as psychiatric diagnosis, hormone treatment, genital surgery, or sterilization. In the scientific literature, a frequent pathologization of trans experiences can be identified, by means of pathologizing conceptualizations, terminologies, visual representations, and practices, as well as ethnocentric biases. Trans activism and scholarship have questioned widely the pathologization of trans people in clinical practice and research. Over the last decade, an international trans depathologization movement emerged, demanding, among other claims, the removal of the diagnostic classification of transexuality as a mental disorder, as well as changes in the health care and legal context. International and regional bodies built up a human rights framework related to sexual, gender and bodily diversity that constitute a relevant reference point for trans depathologization activism. The Yogyakarta Principles, published in 2007 and extended in 2017 by means of the Yogyakarta Principles plus 10, establish an application of international human rights law in relation to sexual orientation, gender expression, gender identity, and sex characteristics. International and regional human rights bodies included demands related to depathologization in their agenda. More recently, advancements towards trans depathologization can be observed in the diagnostic classifications, as well as in the health care and legal context. At the same time, trans people continue being exposed to pathologization and transphobic violence. The Human Rights in Patient Care (HRPC) framework offers a human right-based approach on health care practices. The paper aims at analyzing the shared human rights focus and potential alliances between the trans depathologization perspective and the HRPC framework.

Ungodly Genders: Deconstructing Ex-Gay Movement Discourses of “Transgenderism” in the US

This research investigates a neglected topic within both transgender studies and religious studies by analyzing ex-gay movement discourses of “transgenderism” from the 1970s to the present, focusing primarily on the US-American context. The oppression of transgender people in the US and globally is fed and fueled by the religious, scientific, and political discourses of the transnational “ex-gay” movement, which provides the ideological and material foundation of Christian Right politics. Using critical discourse analysis of ex-gay texts, we analyze the implications of these discourses in the individual, interactional, and institutional dimensions of society’s gender structure. This movement is one of the most insidious—and overlooked—sources of cisgenderism and transmisogyny today, constructing gender variance as sin, mental illness, and danger—with catastrophic consequences for transgender people, and those along the transfemale/feminine spectrum in particular. Finally, we discuss the public policy implications of these discourses.

[Statement by the Spanish Paediatric Association in relation to gender diversity in childhood and adolescence: Ethical and legal view from a multidisciplinary perspective]

An ethical and legal view of gender diversity in childhood and adolescence is presented from the perspective of the best interest of the child and the principle of protection against vulnerability. The identification of gender diversity in childhood and adolescence is a process that requires support, coordination and a multidisciplinary team that improves care and helps to obtain evidence that is lacking today. Secure, equitable and comprehensive access to care and health care should be guaranteed when required. It is necessary to promote a changing of social outlook, capable of overcoming the stereotypes that lead to discrimination and increase suffering. Respect for gender diversity in childhood and adolescence is a fundamental Human Right. The recognition of a positive value in diversity is an ethical imperative. All of this, without forgetting that we are talking about minors often in contexts of vulnerability, and currently very uncertain, so prudence is the main rule that should guide decision-making.