Mental health and quality of life outcomes of gender-affirming surgery: A systematic literature review

The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth

PURPOSE

Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB).

METHODS

In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr).

RESULTS

We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group.

CONCLUSION

Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

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.

Depression and thoughts of self-harm or suicide among gender and sexually diverse people in a regional Australian community

ISSUES ADDRESSED

There is a paucity of data regarding depression and thoughts of self-harm or suicide among gender and sexually diverse (GSD) people living within Australian regional/rural locations. This study aims to elucidate these issues and fill a critical gap.

METHODS

The sample included 91 GSD people from a regional community in South-West Queensland utilising the PHQ-9 to determine presence/severity of depression and self-harm/suicide ideation. These data were drawn from a larger health and wellbeing survey. Raw mean scores were calculated to determine prevalence/severity of clinical symptoms. Bayesian ordinal regression models were employed to analyse between-subgroup differences in depression and self-harm/suicide ideation.

RESULTS

Overall, 80.2% of GSD sample experienced depression (35.2% severe, 45.1% mild/moderate) and 41.8% experienced self-harm/suicide ideation in the past two-weeks. Trans and nonbinary people experienced higher levels of depressions than sexually diverse cisgender people. Pansexual and bisexual people experienced higher levels of depression than gay people. Trans people experienced higher prevalence of self-harm/suicide ideation than cisgender and nonbinary people, with no differences between sexuality subgroups.

CONCLUSIONS

These findings contribute to deeper and more nuanced insights regarding clinically salient depressive and self-harm/suicide ideation symptoms among trans, nonbinary, bisexual, pansexual and queer people in regional Australian communities, with the aim to ultimately reduce mental health prevalence, improve mental health outcomes and health promotion among GSD people. SO WHAT?: The current findings revealed GSD people experience high prevalence of depression and self-harm/suicide ideation indicating tailored mental health awareness-raising, training and health promotion is warranted to enhance psychological support.

Embracing Spectrum: Celebrating LGBTQIA+ Journeys in Aesthetic Medicine: A Kaleidoscope of Identity

PURPOSE

This synaptic systemised review critically examines the provision of aesthetic medical care to LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more) individuals, assessing both the clinical practices and the educational frameworks that guide interactions with LGBTQIA+ patients in aesthetic settings.

METHODS

Following PRISMA-S guidelines, a comprehensive review was conducted, initially identifying 159 potentially relevant articles. Upon stringent full-text review, 33 studies met the inclusion criteria and were subject to an in-depth thematic analysis. The scope encompassed qualitative studies, quantitative analyses, and a cross section of interdisciplinary research, predominantly from Western settings.

RESULTS

The analysis distilled four principal themes: the imperative of identity affirmation in aesthetic interventions, substantial barriers to inclusive and empathetic care, the critical need for patient empowerment, and the existing deficiencies within medical education regarding LGBTQIA+ care. These themes highlight a complex interplay between the clinical aspirations of LGBTQIA+ individuals and the current capacity of aesthetic medicine to cater to this diversity.

CONCLUSIONS

There is a pressing need for a paradigmatic shift towards more inclusive, competent, and sensitive aesthetic medical care for LGBTQIA+ patients. It underscores the necessity of reform in medical education and advocates for policy changes that promote a more equitable healthcare environment. This research serves as a call to action, emphasizing the ethical imperative to integrate comprehensive LGBTQIA+ care competencies into aesthetic medicine curricula and practice.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Agents of scientific uncertainty: Conflicts over evidence and expertise in gender-affirming care bans for minors

Globally, as medical and mental health associations increasingly have expressed support for the gender-affirming care model for trans and gender expansive youth, this model has been paradoxically banned across the United States. Ban proponents have deemed the science behind gender-affirming care to be dangerously uncertain. Examining the first gender-affirming care ban for minors, Arkansas's Save Adolescents from Experimentation (SAFE) Act of 2021, we addressed the following two questions: 1) who are the scientists, clinicians, and political organizations that promote SAFE and similar bans?; and 2) what are the scientific arguments they make to defend SAFE in federal court? First, we developed a typology of the various "agents of scientific uncertainty" behind these bans, drawing on literature from the sociology and history of science and medicine as well as the political economy of scientific doubt. Second, we created and qualitatively analyzed a dataset featuring 375 unique citations referenced throughout federal litigation over SAFE to identify these agents of scientific uncertainty's arguments. We sorted these arguments into eight categories, which reveal how agents distorted scientific evidence and exaggerated real uncertainties and risks in gender-affirming care. This case study establishes a frame for understanding the growing prevalence and legal impact of scientific arguments against gender-affirming care.

Gender affirmation and mental health in prison: A critical review of current corrections policy for trans people in Australia and New Zealand

BACKGROUND

Trans people in prison experience disproportionate rates of harm, including negative mental health outcomes, and thus require special protections. Instead, corrections policies have historically further marginalised them. This critical policy review aimed to compare corrections policies for trans people in Australia and New Zealand with human rights standards and consider their mental health impact.

METHODS

Online searches were conducted on corrections websites for each state/territory in Australia and New Zealand. Drawing on the Nelson Mandela Rules and Yogyakarta Principles, 19 corrections policies relevant to placement, naming, appearance and gender-affirming healthcare for trans people were reviewed. The potential mental health impact of these policies on incarcerated trans people was discussed using the Gender Minority Stress and Resilience framework.

RESULTS

Australian and New Zealand corrections policies have become more concordant with human rights standards in the past 5 years. However, gender-related discrimination and human rights violations were present in corrections policies of all jurisdictions. New South Wales and Victorian policies had the highest concordance with human rights standards, while Queensland and South Australian policies had the lowest.

CONCLUSION

Policies that contribute to discrimination and minority stress may increase risk of mental health problems and suicide for incarcerated trans people. Mental health professionals working in prisons need to be aware of these risks to provide safe and accessible mental healthcare for trans people. Collaborative policy development with trans people is essential to protect the safety and rights of incarcerated trans people and consider models beyond the gender binary on which correctional systems have been founded.

Erasure of the young trans person: A critical discursive review of contemporary health care literature

INTRODUCTION

Trans youth experience significantly higher rates of societal violence and ill-health compared to their cisgender peers. Although recent clinical guidelines for trans young people in health have paved the way for revolutionizing care, many trans young people still experience adversity in clinical settings. This discursive literature review provides a novel approach in exploring why trans young people experience violence in health care despite the availability of evidence-based resources and guidelines.

DESIGN

Databases (CINAHL and Scopus) were systematically searched to identify qualitative literature on the experiences of trans young people (<18 years) in health care settings.

METHOD

Rather than synthesizing and presenting the literature, Fairclough's (2001) CDA methodology was used to critically analyze the literature as texts in a data corpus. The authors engaged with the data from a critical social theory perspective.

RESULTS

Fifteen qualitative articles and one report (n = 16) on the experiences of trans young people (3-24 years) in health care settings were included. Two key discourses were identified in the literature. First, discourses that constituted the trans young person were identified in the definitions of 'trans' as a pathological incongruence and as alternate, self-determined ways of being. Further discourses were identified in the constitution of trans young people as victims, extra-pathological, and alternatively problematised as socially dysphoric. Second, discourses in health provider responses were identified in dismissive, gatekeeping, regulatory, and respectful practices.

DISCUSSION

The discursive constitution of the trans young person as incongruent, vulnerable, and pathological is constituted and generated by dismissive, gatekeeping, and regulatory practices of health care providers. The analysis reveals how trans young people are considered pathological and deemed treatable (at the site of the body), in the interest of 'protecting' them from a perceived abject future of trans adulthood. The logic and violence of cisgenderism is uncovered as the foundation of these dominant discourses, whereby growing up cisgender is often presented as the only option in health care settings. The dominant discourses that constitute the trans young person in health care as incongruent, pathological, and vulnerable, alongside the reifying health care responses of dismissal, gatekeeping, and regulation contribute to the erasure of the young trans person.

CONCLUSION

This paper identified key discourses in the literature in how trans young people are constituted and regulated in health care. This review highlights an urgent need for further critical scholarship in trans health by trans researchers, from critical perspectives. Furthermore, it provides a starting point for critical reflection of health care provider and researcher practices and the re-imagination of trans-futurity for all young people in health care.

CLINICAL RELEVANCE

Nurses are situated at the forefront of health care delivery and play a crucial role in the advocacy and provision of culturally safe care. With this ideal proximity to clients, nurses can powerfully affect change through better understanding and reflecting on how regulatory practices constitute and position trans young people in health care. Nursing knowledge, such as cultural safety, can offer novel approaches in working towards safer ways of meeting the needs of trans young people.

Fostering Gender-IQ: Barriers and Enablers to Gender-affirming Behavior Amongst an Australian General Practitioner Cohort

While the visible population of trans and gender diverse Australians has grown significantly in recent years, primary health-care access remains hindered by a lack of practitioner competency and stigmatization. This article draws on qualitative research of purposively selected gender-affirming general practitioners (GPs) in Australia to explore barriers, and enablers when treating trans and gender diverse patients. Perspectives and behaviors during the gender-affirming clinical encounter were theoretically informed through minority stress theory, and master narrative frameworks. Reflexive thematic analysis facilitated a rich description of exemplary gender-affirming primary care. A considerable gap exists between structural, clinical, and cultural behaviors among competent gender-affirming GPs in Australia, and the majority of practitioners evidenced in the literature. This critical analysis contributes to better understanding how gender-affirming Australian GPs diffuse minority stress, negotiate cis-normative biases, and foster a person-centered longitudinal therapeutic relationship with their trans and gender diverse patients. An encounter the article argues may also provide an essential buffer for GPs in Australia against the risk of professional burnout. Gender-affirming practice should be taught as a core competency and be required as professional development for GPs in Australia, to ensure a beneficial clinical encounter for the growing trans and gender diverse population.

Correctional staff knowledge, attitudes and behaviors toward incarcerated trans people: A scoping review of an emerging literature

Background: Trans people are incarcerated at disproportionately high rates relative to cisgender people and are at increased risk of negative experiences while incarcerated, including poor mental health, violence, sexual abuse, dismissal of self-identity, including poor access to healthcare. Aims: This scoping review sought to identify what is known about the knowledge, attitudes, and behaviors of correctional staff toward incarcerated trans people within the adult and juvenile justice systems. Method: This scoping review was conducted in accordance with the five-stage iterative process developed by Arksey and O'Malley (2005), utilizing the PRISMA guidelines and checklist for scoping reviews and included an appraisal of included papers. A range of databases and grey literature was included. Literature was assessed against predetermined inclusion and exclusion criteria, with included studies written in English, online full text availability, and reported data relevant to the research question. Results: Seven studies were included with four using qualitative methodologies, one quantitative, and two studies employing a mixed methods approach. These studies provided insights into the systemic lack of knowledge and experience of correctional staff working with trans people, including staff reporting trans issues are not a carceral concern, and carceral settings not offering trans-affirming training to their staff. Within a reform-based approach these findings could be interpreted as passive ignorance and oversights stressing the importance of organizational policies and leadership needing to set standards for promoting the health and wellbeing of incarcerated trans persons. Conclusions: From a transformational lens, findings from this study highlight the urgent need to address the underlying structural, systemic, and organizational factors that impact upon the knowledge, attitudes, and behaviors staff have and hold in correctional, and other health and community settings to meaningfully and sustainably improve health, wellbeing, and gender-affirming treatment and care for trans communities, including make possible alternative methods of accountability for those who do harms.

Quality of life of transgender people under the lens of social determinants of health: a scoping review protocol

INTRODUCTION

There is an urgent need for knowledge about the transgender population to inform the development of clinical protocols and training of health professionals on the unique issues affecting this population. Discussing transgender quality of life (QoL) through the lens of social determinants of health (SDOHs) would enable gender-specific health interventions. Here, we aimed to review the evidence on the QoL of transgender people from an SDOH perspective.

METHODS AND ANALYSIS

A scoping review (ScR) protocol following the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews statement and guided by the Joanna Briggs Institute was used. MEDLINE/PubMed, Cochrane Library, Embase, PsycINFO, Web of Science, Scopus and registry sites such as ClinicalTrials.gov and WHO ICTRP will be searched. Additional sources to be searched include ProQuest Dissertations/Theses Global, British Library, Google Scholar and Preprints for Health Sciences-medRXiv. Two independent researchers will carry out the selection, data charting and data synthesis. No date restriction will be applied in this ScR. The search will be restricted to articles published in English, Spanish and Portuguese. The results will be presented in tables, narrative summaries and graphs and will be graded on the type of data presented and the results. The search strategy will be updated in April 2023. The expected completion date of this ScR is July 2023.

ETHICS AND DISSEMINATION

This ScR protocol does not require ethical approval. Dissemination plans include peer-reviewed publications, conference presentations to be shared with experts in the field, and advisory groups to inform discussions on future research. It is hoped that our findings will be of interest to practitioners, researchers, stakeholders, public and private managers, and the general population concerned with this emerging public health issue.

TRIAL REGISTRATION NUMBER

osf.io/9ukz6.

Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand

BACKGROUND

Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities.

METHODS

Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14-26 years; n = 608; Mage = 20.5).

RESULTS

Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02-3.98) of having attempted suicide in the last 12 months.

CONCLUSIONS

Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth.

Instruments used to assess gender-affirming healthcare access: a scoping review protocol

BACKGROUND

 Internationally, the demand for gender-affirming care has increased exponentially in recent years. The clinical presentation of those seeking care has changed with an increase in transmasculine and non-binary identities and a decrease in the average age of those seeking care. Healthcare navigation remains complicated for this population and warrants further investigation in light of ongoing changes in the field. This paper presents a protocol for a scoping review to map and synthesise the academic and grey literature on instruments used to assess healthcare navigation and access for transgender and non-binary individuals seeking gender-affirming care.

METHODS

This review will search databases (PsychINFO, CINAHL, Medline, and Embase.) and grey literature sources. In line with the methodological framework for scoping reviews, the following six stages will be undertaken: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation will be utilised and reported. The research team will undertake the study as outlined in this protocol and an expert panel of young transgender and non-binary youth will oversee the project through patient and public involvement.  Conclusions: This scoping review has the potential to inform policy, practice, and future research through enhanced understanding of the complex interplay of factors that impact healthcare navigation for transgender and non-binary people seeking gender-affirming care. The results from this study will inform further research into healthcare navigation considerations generally and will inform a research project entitled "Navigating access to gender care in Ireland-a mixed-method study on the experiences of transgender and non-binary youth".

Navigating Detransition Borders: An Exploration of Social Media Narratives

Detransition, a relatively recent phenomenon within academic discourse and mainstream media, refers to individuals who transition from the gender they transitioned into. Experiences of detransition, including those shared on social media, are poorly understood. Drawing upon narratives of gender detransition as shared on a global social media site, this analysis explores and seeks to better understand how detransition experiences are shared; and the effect of detransition narratives on gendered embodiment and belonging. Employing Butler's (Undoing gender. Routledge, 2004) notion of livable lives and Crawford's (Seattle J Soc Justice 8(2):515-539, 2010) conception of trans architecture, this analysis theoretically extends trans conversations to include discourses and narratives of detransition. A total of 130 archival posts by 36 contributors relating to detransition were collected from a popular global social media site where the engagement of reflexive thematic analysis contributed to the development of three themes: Contemplating transformation; Experiences of detransition; and Prominent discourses for detransition. Study findings suggest that detransition narratives expressed on this social media site demonstrate the multifaceted and complex ways in which non-normative gendered lives are rendered unlivable. In response, this analysis problematizes gender by conceptualizing detransition as a transformation toward a trans space outside a cisnormative frame contributing to making gendered lives more livable.

Instruments used to assess gender-affirming healthcare access: a scoping review protocol

Background: Internationally, the demand for gender-affirming care has increased exponentially in recent years. The clinical presentation of those seeking care has changed with an increase in transmasculine and non-binary identities and a decrease in the average age of those seeking care. Healthcare navigation remains complicated for this population and warrants further investigation in light of ongoing changes in the field. This paper presents a protocol for a methodological scoping review that aims to systematically map and synthesise the extent and nature of the peer-reviewed, published academic literature on the instruments used to assess factors relating to healthcare navigation and healthcare access for transgender and non-binary individuals seeking gender-affirming healthcare.  Methods: This review will search databases (PsychINFO, CINAHL, Medline, and Embase.) and grey literature sources. In line with the methodological framework for scoping reviews, the following six stages will be undertaken: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation will be utilised and reported. The research team will undertake the study as outlined in this protocol and an expert panel of young transgender and non-binary youth will oversee the project through patient and public involvement.  Conclusions: This scoping review has the potential to inform policy, practice, and future research through enhanced understanding of the complex interplay of factors that impact healthcare navigation for transgender and non-binary people seeking gender-affirming care. The results from this study will inform further research into healthcare navigation considerations generally and will inform a research project entitled “Navigating access to gender care in Ireland—a mixed-method study on the experiences of transgender and non-binary youth”.

A trans agent of social change in incarceration: A psychobiographical study of Natasha Keating

OBJECTIVES

This psychobiography focuses on the advocacy work of Natasha Keating, a trans woman incarcerated in two male prisons in Australia between 2000 and 2007. Incarcerated trans women are a vulnerable group who experience high levels of victimization and discrimination. However, Natasha advocated for her rights while incarcerated and this advocacy contributed to substantial changes in the carceral system. This psychobiography uses psychological understandings of resilience as well as the Transgender Resilience Intervention Model (TRIM) to investigate the factors that enabled this advocacy.

METHOD

Data consisted of an archive of letters written by Natasha and interviews with individuals who knew her well. This psychobiography was guided by du Plessis' (2017) 12-step approach and included the identification of psychological saliencies and the construction of a Multilayered Chronological Chart.

RESULTS

Natasha's life is presented in four chapters, with each chapter including a discussion of resilience based on the TRIM.

CONCLUSIONS

The TRIM suggests that during incarceration, Natasha was able to access more group-level resilience factors than at any other time in her life. This, combined with individual resilience factors, enabled her advocacy. This finding has implications for advocacy in general as it highlights the importance of both individual- and group-level factors in enabling individuals to effectively advocate for change in their environments.