The Social Costs of Gender Nonconformity for Transgender Adults: Implications for Discrimination and Health

"There is No One Way to Be Transgender and to Live Sex": Transgender and Non-Binary Individuals' Experiences with Pornography

Transgender or non-binary (TGNB) people are often present as protagonists of pornographic material. This study is the first to consider TGNB people as critical consumers of sexually explicit material. The sample included 212 self-identified TGNB individuals: 47.2% trans man/transmasculine, 15.6% trans woman/transfeminine and 37.3% non-binary. The online questionnaire consisted of a sociodemographic data collection, multiple-choice questions about preferences and habits concerning pornography, and open-ended questions about the sensations experienced when watching pornography, opinions on the representation of TGNB people in pornography, and their experience in watching pornographic videos with cisgender or TGNB protagonists. The answers were analyzed using the qualitative method of thematic analysis. We identified four themes that appeared across the responses: 1) heteronormativity and cisnormativity in pornography: the need for deconstructing the current cis-het-patriarchial normative and binary system, which dominates pornography except for the ethical porn industry, 2) cisgender pornography compared to TGNB pornography, 3) pleasurable sensations (e.g., identification and empowerment) associated with TGNB pornography, and 4) negative sensations (e.g., objectification and dysphoria) associated with TGNB pornography. Results are discussed in light of the objectification framework and the minority stress model.

Barriers to correct pronoun usage in healthcare settings

BACKGROUND

Using correct pronouns is an impactful way to establish affirming environments for transgender and nonbinary (TGNB) patients. However, physicians often report struggling with this.

OBJECTIVE

This study set out to conduct an initial root cause analysis of factors contributing to medical students and physicians failing to use TGNB patients' correct pronouns.

METHODS

A 10-item Qualtrics survey was sent to medical students, residents, and physicians practicing in Central Ohio. Participants were asked to describe perceived challenges or barriers colleagues have regarding correctly using TGNB patients' correct pronouns. A directed content analysis of participant responses was performed utilizing a fishbone diagram root cause analysis tool as a basis for conceptualizing and categorizing barriers. All coding was completed by independent reviewers utilizing a consensus reconciliation methodology.

RESULTS

Of 928 survey respondents, 763 met the study inclusion criteria, of which 453 provided analyzable responses. Of these 453, attendings with five or more years of practice (32.5%) and medical students (27.4%) made up the two largest demographic categories. 1.7% of respondents identified as transgender, nonbinary, and/or genderqueer, and 64% identified as heterosexual/straight. Five core barrier categories were identified: documentation, patient care, environment, knowledge, and individuals. Sub-categories were also identified, including lack of documentation, discomfort, medical culture, lack of standardization, prejudice, and assumptions.

CONCLUSION

The study identifies important barriers to medical professionals correctly using TGNB patients' pronouns. The root cause analysis conducted as part of this study demonstrates the necessity of multi-pronged, system-level interventions to support ensuring TGNB patients are addressed using the correct pronouns.

[DIVERGesTOOL-development of a toolbox for the assessment of sex/gender diversity]

In health research, there is a need for comprehensive survey instruments capable of assessing the multidimensionality and variability of sex/gender. The research project DIVERGesTOOL was conducted in response to this need, which has become increasingly evident in recent years. The aim was to develop an application-oriented toolbox for the assessment of sex/gender diversity in quantitative health-related research in Germany.The development process followed a participatory design, as representatives of large epidemiological studies in Germany were directly involved. During four collaborative workshops, a toolbox was developed that contains several different elements. The basic items are a generally usable set of three different questionnaire items based on the two-step approach. They are recommended as a replacement for the binary sex or gender item that are currently routinely used in health-related research. In addition, the toolbox contains further exemplary questionnaire items for specific research questions or study populations. The developed items were supplemented with detailed instructions for their application and additional information. The toolbox is an open online resource accessible to any user ( https://www.uni-bremen.de/divergestool-projekt/divergestool-toolbox ).In the long term, the DIVERGesTOOL is intended to support researchers in integrating sex/gender diversity into their own research and thus to contribute to more sex/gender sensitivity in health-related research and valid findings.

Transgender Health Dilemmas: An Intersectional Analysis of the Therapeutic Itineraries of Transgender Communities in the Philippines

This study leverages an intersectional lens to characterize the therapeutic itineraries of local transgender (trans) communities vis-à-vis salient cisnormative and capitalist structures in Philippine society that produce trans health inequities. Interpretative phenomenological analysis of online interviews with thirteen (13) self-identified trans Filipinos reveals how the inaccessibility of trans-responsive care in the Philippines fosters trans health dilemmas, or the dilemmatic decision-making circumstances and processes that force trans Filipinos to choose between their trans-specific health needs and other needs. Such dilemmas valorize the deprioritization of trans health, disengagement with the health system, and the pursuit of alternative pathways to care oftentimes at the expense of their overall well-being. Addressing these dilemmas entails research, policy, and advocacy work that contend with the implicated structures of domination through systemic interventions initiated in partnership with local trans communities.

Transformative tales: The role of story videos on children's reasoning about transgender identities

The current study explored whether positive contact through stories could influence how young children think about transgender identities and gender in general. A total of 174 children ages 5-6 and 9-10 were randomly assigned to one of three conditions: Jazz (participants watched a video regarding a transgender child named Jazz), Blue (participants watched a video regarding a marker that looked red on the outside but inside was really blue) and control (no video). Both videos described the main character as feeling different inside than outside, and their social transition to their preferred identity; researcher scaffolding supported the video messages. Children who viewed the Jazz video had: (a) greater understanding of transgender identities and (b) no overall differences in gender essentialism, but (c) lower gender essentialism on three specific measures (gender immutability, innate toy behaviours and innate preferences). Also, gender essentialism was lower in older versus younger children. In this study, a direct, realistic story was the only effective means of teaching children about transgender identities and reducing belief in gender immutability. Thus, stories can be a way to teach children about the social world and change essentialist beliefs, but the impact may be limited and greatly affected by features of the story.

"I would prefer to be dead than to live this way": Lived experiences of stigma and discrimination against khwaja sira in Swat, Pakistan

Due to their identification as third gender people, khwaja sira have historically been subjected to experiences of social marginalization. However, the extant literature has not fully explored the lived experiences of stigma and discrimination against khwaja sira in the Swat Valley of Khyber Pakhtunkhwa, Pakistan. To address this gap, we conducted 45 interviews with khwaja sira in Mingora, Swat, Khyber Pakhtunkhwa to better understand their experiences of gender-nonconformity stigma and discrimination in various social contexts, including within their families, in accessing health care, and within education and work contexts. Applying Minority Stress Theory and utilizing thematic content analysis, the present study identified three dimensions of gender-nonconformity stigma: (1) internalized stigma, namely feelings of shame and embarrassment; (2) perceived stigma, namely opinions others had of khwaja sira regarding lack of employability or engagement in sex work; and (3) enacted stigma, namely exclusion from families, in educational settings, in religious spaces, and in healthcare settings. Findings should inform future social intervention and community practice engagements with khwaja sira communities in Pakistan.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Elements of Minority Stress and Resilience in LGBTQ+ Students' Experience of Education

This study investigates the experiences of minority stress and resilience among LGBTQ+ students in educational settings and identifies critical contributors to their well-being. To highlight the unique educational experiences of LGBTQ+ participants a qualitative research strategy was employed. We conducted narrative interviews with 27 LGBTQ+ people aged 17 to 41 who are or have been enrolled in primary, secondary or tertiary education in Slovenia. The results indicate that minority stress is a significant in their educational experiences, with various deleterious effects. The testimonies of our respondents indicate, albeit to a lesser extent, that the education system can enhance the resilience of LGBTQ+ youth and mitigate the negative impacts of minority stress. This study confirms prior research on minority stress effects on LGBTQ+ individuals. It asserts that LGBTQ+ youth experience minority stress within the education system, while emphasizing that certain aspects of resilience can significantly mitigate these negative effects. As social support emerged as a significant factor in our study, it would be reasonable to investigate how school personnel can enhance LGBT youths' resilience in the future. Additionally, it would be beneficial to investigate how the support of peers and (chosen) families influences the school experiences of LGBTQ+ students.

Loud, Proud, and All Around Hilarious: Queer Humor in Contemporary Graphic Novels as a Method of Interpersonal Affirmation and Awareness

Despite the prevalent humor in political, performative, and personal means of expression throughout American LGBTQ+ history, there is not yet an academic analysis on the overlap between queer theory and humor theory. In this article, I explore the ways in which LGBTQ+ writers use humorous techniques to highlight aspects of queerness to establish a theory of queer humor. I rely on three contemporary graphic narratives as a platform for humorous expression and for challenging social expectations, specifically in regards to LGBTQ+ identities and experiences. Through these close readings, I find queer humor exposes cultural policings of gender performativity by promoting queer experiences over normative assumptions and building solidarity with the reader regardless of their identity. These methods encourage acknowledgments and accommodations of queer existence within a heterosexist society.

Mental Health and Marginalization Stress in Transgender and Gender Diverse Adults: Differences between Urban and Non-Urban Experiences

Background

Transgender and gender diverse (TGD) individuals face high rates of psychological distress, including depression, anxiety, and suicide risk. Further, TGD individuals living outside of urban areas experience additional disparities compared to their urban counterparts. Minority stress theory states that minority stressors (termed marginalization stressors for this paper), such as experiences of discrimination and internalized transphobia, lead to psychological distress. The current study compared marginalization stressors across rural (population less than 2,500), urban cluster (population between 2,500 and 50,000), and urban (population greater than 50,000) samples and tested the degree to which these stressors account for differences across areas of residence.

Methods

Participants were 225 TGD individuals who completed an online survey that included measures of depression, anxiety, suicidal ideation marginalization stress, and protective factors.

Results

In the first model, mental health outcomes, marginalization stressors, and protective factors differed between areas. Urban cluster participants reported experiencing higher levels of depression, anxiety, and suicidal ideation and rural participants reported experiencing higher levels of depression suicidal ideation than urban participants. Both rural and urban cluster participants reported more experiences of several marginalization stressors. In the subsequent path model, indirect effects between area and marginalization stress variables were significant, but urban cluster participants still reported higher depression, anxiety, and suicidal ideation symptoms (p-values < .05).

Discussion

We demonstrate that marginalization stress processes appear to account for some of the differences between TGD individuals living in urban, rural, and urban cluster areas. The differences between areas largely persist, however, after controlling for marginalization stress, especially when comparing urban with urban cluster areas.

Facilitating Gender-Affirming Nursing Encounters

The purpose of this article is to highlight the essentials for facilitating gender-affirming nursing encounters for transgender, nonbinary, and other gender expansive (TNGE) people. The authors illustrate what constitutes as gender-affirming nursing encounters by characterizing gender-affirming approaches to conducting and documenting a nursing assessment and describing techniques to overcome institutional-level challenges that may hinder a nurse's ability to establish gender-affirming therapeutic relationships with TNGE people. The authors also provide strategies that nurses can use to improve their health care organization and interprofessional collaborative practice to create psychologically and physically safe health care spaces for TNGE people.

The Relationship of Anti-Transgender Discrimination, Harassment, and Violence to Binge Drinking among Transgender Adults

Purpose: Using a minority stress paradigm, this paper examines the relationship between anti-transgender discrimination, harassment, and violence among transgender adults. Methods: Data from the 2015 U.S. National Transgender Survey were used to examine twenty types of anti-transgender experiences/problems (e.g., harassment at work, problems with police officials, verbal and physical assaults) in a sample of 27,715 transgender Americans aged 18 or older. Binge drinking during the previous month was the dependent variable, and eight control measures were examined in the multivariate analysis. Results: Experiencing any of the twenty types of anti-transgender discrimination, harassment, or violence increased the odds of binge drinking by 48%. Experiencing many such problems increased the odds of binge drinking by 104%. Multivariate analysis showed that anti-transgender discrimination, harassment, and violence remains a predictor of binge drinking even when other key measures are taken into account. Younger people, racial minority group members, and persons who were not married or "involved" were at particularly great risk. Conclusions: Consistent with the minority stress paradigm, the more different types of anti-transgender experiences people had, the more likely they were to engage in binge drinking. Targeted intervention needs to help transgender persons to avoid anti-transgender discrimination, harassment, and violence to the greatest extent possible, and to develop resiliency skills whenever they are victimized. This is particularly true for transgender persons who are younger, minority, and not "involved" in a relationship.

Detectable viral load associated with unmet mental health and substance use needs among trans women living with HIV in San Francisco, California

BACKGROUND

Substance use and mental distress are known barriers to HIV care engagement among trans women. Less is known about access and utilization of mental health and substance use care among trans women and the relationship between unmet behavioral health needs and HIV viral suppression. We examined the relationship between mental health and substance use on HIV viral load among trans women living with HIV. We also examined the relationship between mental health and substance use services needs with HIV care engagement and having a detectable viral load by comparing engagement in care cascades.

METHODS

Data are from a 2022 baseline assessment for an intervention with trans women living with HIV (n = 42) in San Francisco. Chi-Squared or Fisher's exact tests were conducted to determine associations between HIV viral load, mental health, and substance use. We also examine characteristics associated with each step in the HIV, mental health, and substance use care cascades.

RESULTS

Most participants were trans women of color (85.7%), 40 years of age or older (80.9%), with low income (88.1%), and almost half were unstably housed (47.6%). Of the 32 participants who screened positive for depression, anxiety and/or psychological distress, 56.3% were referred for mental health services in the past 12 months. Of those who were referred, 44.4% received mental health services. Of the 26 participants who screened positive for a substance use disorder, 34.6% were referred to substance use services in the past 12 months. Of those referred, 33.3% received substance use services in the past 3 months. Latina trans women had a low referral rate to meet their mental health needs (50%) and only 16.7% of African American/Black trans women who screened positive for a substance use disorder were referred for services, while trans women of other race/ethnicities had high referral and services utilization. No significant results were found between HIV viral load and screening positive for a mental health disorder. Methamphetamine use was statistically associated with having a detectable HIV viral load (p = 0.049).

CONCLUSIONS

We identified significant unmet mental health and substance use services needs and noted racial/ethnic disparities in the context of high HIV care engagement among trans women living with HIV. We also found that methamphetamine use was a barrier to having an undetectable viral load for trans women living with HIV. To finally end the HIV epidemic, integration of behavioral health screening, linkage, and support are needed in HIV care services for populations most impacted by HIV, especially trans women.

TRIAL REGISTRATION

NCT, NCT 21-34,978. Registered January 19, 2022.

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.

Group differences in gender expression discrimination and depressive and anxiety symptoms among transgender and gender-expansive adults: The role of gender identity pride

Despite established associations between discrimination and mental health, little research has focused on gender expression discrimination and integrated individual strengths such as transgender and gender-expansive (TGE) identity pride. This study examined the roles of gender expression discrimination and pride in mental health among TGE adults across gender identity, race, and class. A national sample of TGE adults (N = 212) completed online measures assessing gender identity, race, income, gender expression-related discrimination, TGE identity pride, and depression and anxiety symptoms. Gender expression discrimination was positively associated with depressive and anxiety symptoms. Black, Indigenous, People of Color (BIPOC), higher income, transfeminine participants reported more gender expression discrimination. High TGE identity pride buffered the association between gender expression discrimination and depression-most robustly for BIPOC, lower income, transfeminine participants. TGE identity pride may buffer the effects of gender expression discrimination on depression. Intersectionality in case formulation and treatment planning with TGE individuals is vital.

The Mediating Role of Avoidant and Facilitative Coping on the Relation Between Discrimination and Alcohol Use Among Transgender and Gender-Diverse Individuals

Purpose

The motivational model of alcohol use indicates that there is a relation between chronic stress and alcohol use, and that this relation is mediated by substance use to cope. However, this model has not been applied to the experiences of transgender and gender-diverse (TGD) individuals. In response, this study investigated whether facilitative (e.g., active and interpersonal coping) and avoidant (e.g., cognitive avoidance and substance use to cope) coping mediate the relation between discrimination and alcohol use.

Methods

Participants include 496 TGD individuals (97 trans women, 126 trans men, and 273 nonbinary), 18-68 years of age (mean=32.09 and standard deviation=12.47), who completed a survey about health behaviors and stress. An exploratory factor analysis and confirmatory factor analysis of the Brief Coping Orientation to Problems Experienced (COPE) were conducted to determine the coping patterns of TGD individuals and multiple mediation analyses were conducted to examine whether distinct coping strategies mediated the relation between discrimination and alcohol use.

Results

Both facilitative and avoidant coping strategies were significantly related to discrimination; however, only active coping and substance use to cope were related to alcohol use. Mediation results showed that substance use to cope (i.e., an avoidant coping strategy) was the only significant mediator. Descriptive results showed nonsignificant differences between TGD gender identities regarding levels of alcohol use and engagement with coping strategies.

Conclusion

The results indicate a clear need for interventions to reduce utilization of avoidant coping strategies among TGD individuals.

Collective self-understanding: A linguistic style analysis of naturally occurring text data

Understanding what groups stand for is integral to a diverse array of social processes, ranging from understanding political conflicts to organisational behaviour to promoting public health behaviours. Traditionally, researchers rely on self-report methods such as interviews and surveys to assess groups' collective self-understandings. Here, we demonstrate the value of using naturally occurring online textual data to map the similarities and differences between real-world groups' collective self-understandings. We use machine learning algorithms to assess similarities between 15 diverse online groups' linguistic style, and then use multidimensional scaling to map the groups in two-dimensonal space (N=1,779,098 Reddit comments). We then use agglomerative and k-means clustering techniques to assess how the 15 groups cluster, finding there are four behaviourally distinct group types - vocational, collective action (comprising political and ethnic/religious identities), relational and stigmatised groups, with stigmatised groups having a less distinctive behavioural profile than the other group types. Study 2 is a secondary data analysis where we find strong relationships between the coordinates of each group in multidimensional space and the groups' values. In Study 3, we demonstrate how this approach can be used to track the development of groups' collective self-understandings over time. Using transgender Reddit data (N= 1,095,620 comments) as a proof-of-concept, we track the gradual politicisation of the transgender group over the past decade. The automaticity of this methodology renders it advantageous for monitoring multiple online groups simultaneously. This approach has implications for both governmental agencies and social researchers more generally. Future research avenues and applications are discussed.

Sexual orientation, gender expression and socioeconomic status in the National Longitudinal Study of Adolescent to Adult Health

BACKGROUND

Socioeconomic status (SES) is a fundamental contributor to health, yet it is rarely examined relative to gender expression, particularly gender non-conformity and sexual orientation.

METHODS

We use data from 11 242 Wave V respondents (aged 33-44) in the National Longitudinal Study of Adolescent to Adult Health (2016-2018) to examine associations between socially assigned gender expression, sexual orientation and SES, in logistic and multinomial regression models stratified by sex assigned at birth.

RESULTS

Among both women and men a general pattern of heightened risk for lower SES among gender non-conforming sexual minorities relative to gender conforming heterosexuals was observed. Gender non-conforming heterosexuals were also at elevated risk of lower SES compared with their conforming heterosexual peers.

CONCLUSION

Socioeconomic differences by sexual orientation and gender expression have important implications for understanding health disparities among gender non-conforming sexual minorities and their gender conforming heterosexual counterparts.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Contending with precarity: Digital pathways to sexual and reproductive healthcare among transgender Filipinos during the COVID-19 pandemic

Stringent lockdowns during the COVID-19 pandemic and the cisnormative framing of sexual and reproductive health (SRH) in the Philippines cultivated precarious access to SRH systems among transgender (trans) communities during the public health crisis. With the shift toward digital health initiatives, this study aimed to explore the experiences of the local trans community in using digital health initiatives (DHIs) to access SRH care and gender-affirming services, information, and providers during the COVID-19 pandemic. Online interviews with 13 self-identified trans Filipinos living in the Philippines during the pandemic were conducted and analyzed using interpretative phenomenological analysis. First, the narratives of trans Filipinos illustrate how DHIs can address discontinuities of care that emerged during the COVID-19 pandemic. However, because of long-standing geographic, economic, and social barriers to trans-responsive healthcare in the Philippines, local trans communities navigate alternative pathways to care established within digital spaces (e.g., social media) by trans individuals and groups. These online communities of care not only connect trans Filipinos to culturally competent and affordable care but also foster a sense of belongingness and support. Taken together, this study underscores the need to go beyond technical access to care to ensure that trans-inclusive and trans-responsive sources and providers of care are made available throughout the healthcare system. As the narratives of trans Filipinos illustrate, the narratives, experiences, and practices within their online communities of care may be the key to actualizing such a healthcare system not only in the Philippines but all over the world.

Initial Theoretical Discussion of Identity as Barrier and Facilitator in Voice Habilitation and Rehabilitation

OBJECTIVES

The purpose of this paper is to review seminal identity theories grounded in social psychology and one concept from voice science and explain how this group may point to identity factors facilitating or impeding voice habilitation and rehabilitation.

METHODS

Identity theories from the social psychology literature (Dramaturgical Theory, Self-Categorization Theory, Self-Determination Theory, Identity Negotiation Theory) and vocal congruence are described. Concepts are synthesized with voice science research to explore potential identity-behavior relations at play in voice habilitation and rehabilitation.

RESULTS

Applicable concepts from social psychology and voice science suggest identity-related processes by which a client may or may not develop a voice difference/disorder, seek intervention, and achieve goals in intervention. A bidirectional relationship between identity and behavior has been well-established in the social psychology literature. However, the relevance of vocal behavior has yet to be formally examined within this literature. Importantly, although connections between behavioral tendencies and voice disorders as well as the contribution of identity to gender-affirming voice treatment have been established in the voice science literature, the consideration of identity's possible role in voice habilitation and rehabilitation in cis gender individuals has thus far been scant.

CONCLUSIONS

Research into identity and voice habilitation and rehabilitation may help to improve voice intervention outcomes. A possible adjunct to human studies is agent-based modeling or other computational approaches to assess the myriad factors that may be relevant within this line of inquiry.

Correlates of hazardous alcohol drinking among trans and non-binary people in Canada: A community-based cross-sectional study

PURPOSE

Transgender and non-binary people (TGNB) have a higher rate of heavy episodic drinking than cisgender people; however, extant knowledge about predictors of hazardous alcohol drinking (HAD) among different TGNB groups is limited. This study examined predictors of HAD in a national sample of TGNB people in Canada.

METHODS

Logistic regression models were fit to examine the effects of 1) minority stressors and 2) stress-buffering factors on the likelihood of HAD, stratified by gender, among 2324 TGNB individuals from the Trans PULSE Canada survey, a cross-sectional survey conducted in 2019 among trans and non-binary people aged 14+ in Canada.

RESULTS

Almost 17% of participants reported past-year HAD. Lifetime day-to-day and lifetime major discrimination were associated with higher odds of HAD in the full sample [(AOR=1.37, 95% CI: 1.30, 1.44) and (AOR=1.69, 95% CI: 1.55, 1.86) respectively], and across all gender groups. Social support was associated with lower odds of HAD in trans men, non-binary people assigned female at birth (NB-AFAB), and non-binary people assigned male at birth (NB-AMAB) groups, but with higher odds of HAD in the trans women group. Misgendering was associated with lower odds of HAD in trans men and NB-AFAB, but higher odds of HAD in trans women and NB-AMAB. Mixed effects of gender distress, gender positivity, and gender-affirming medical care were also reported across groups.

CONCLUSION

The study provided a more detailed understanding of the predictors of HAD across four TGNB groups. Public health interventions should focus on structural discrimination and social support for TGNB people.

Gender Affirmation-Related Information-Seeking Behaviors in a Diverse Sample of Transgender and Gender-Diverse Young Adults: Survey Study

BACKGROUND

Of the 1.6 million transgender and gender-diverse (TGD) people in the United States, approximately 700,000 are youth aged 13-24 years. Many factors make it difficult for TGD young people to identify resources for support and information related to gender identity and medical transition. These range from lack of knowledge to concerns about personal safety in the setting of increased antitransgender violence and legislative limitations on transgender rights. Web-based resources may be able to address some of the barriers to finding information and support, but youth may have difficulty finding relevant content or have concerns about the quality and content of information they find on the internet.

OBJECTIVE

We aim to understand ways TGD young adults look for web-based information about gender and health.

METHODS

In August 2022, 102 young adults completed a 1-time survey including closed- and open-ended responses. Individuals were recruited through the Prolific platform. Eligibility was restricted to people between the ages of 18-25 years who identified as transgender and were residents of the United States. The initial goal was to recruit 50 White individuals and 50 individuals who identified as Black, indigenous, or people of color. In total, 102 people were eventually enrolled.

RESULTS

Young adults reported looking on the internet for information about a broad range of topics related to both medical- and social-gender affirmation. Most participants preferred to obtain information via personal stories. Participants expressed a strong preference for obtaining information from other trans people.

CONCLUSIONS

There is a need for accessible, expert-informed information for TGD youth, particularly more information generated for the transgender community by members of the community.

Not Just Checklists and Rainbows: Exploring Canadian Dietitians' Beliefs, Values, and Knowledge of Transgender Nutritional Care

Purpose

Many transgender (short form: trans) people are experiencing disparities within Canadian health care systems, including nutritional and dietetic health care systems. This research explores the views, beliefs, and experiences of Canadian dietitians about trans nutritional care and seeks to understand how dietitians can better address the nutritional needs of trans individuals.

Methods

Semistructured online interviews were conducted with 16 Canadian dietitians. Interviews were transcribed and the data were analyzed thematically.

Results

Three main themes were created; (1) There's an Unjust System, (2) We've Come a Long Way, and (3) Not Just Checklists and Rainbows. The participants explored the historic nature of the Canadian dietetic profession and noted the connection between cis-normativity and the erasure of trans identities. They also explored how dietitians could better address the health needs of trans people, including moving beyond the acknowledgement of trans identities to changing the way gender is viewed in the profession.

Conclusion

The dietetic profession must move beyond surface-level activities and rethink gender. Recommendations include adding trans-focused care training into the profession, creating safer spaces for trans individuals, advocacy and allyship, and recruiting trans people to the profession.

Differential associations between enacted and expected stigma with psychological distress, alcohol use, and substance use in transgender and gender diverse people

BACKGROUND

Transgender and gender diverse (TGD) people experience high rates of stigma and marginalization that are theorized to exacerbate substance use and psychological distress. However, little research has examined the role of various minority stressors in relation to substance use in TGD populations.

METHODS

In this sample of 181 TGD individuals in the U.S. who reported substance use or binge drinking over the past month (M age = 25.6; SD = 5.6), we evaluated whether enacted stigma predicted alcohol use, substance use, and psychological distress.

RESULTS

Participants endorsed a high rate of exposure to enacted stigma over the past 6 months (e.g., 52% had been verbally insulted). Furthermore, 27.8% of the sample was classified as having moderate or higher severity drug use, and 35.4% were classified as having hazardous drinking levels. We found that enacted stigma was significantly related to moderate-high drug use and psychological distress. There were no significant associations between stigma variables and hazardous levels of drinking. Enacted stigma had an indirect effect on psychological distress via increased expectations of stigma.

CONCLUSIONS

This study adds to the growing literature exploring minority stressors in relation to substance use and mental health. Subsequent research is needed to examine TGD-specific factors that may more fully explain how TGD people cope with enacted stigma or that may influence substance use, particularly alcohol use.

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

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

Measuring Geographic Access to Transgender Hormone Therapy in Texas: A Three-step Floating Catchment Area Analysis

While the extant literature has established that transgender people face significant barriers to accessing healthcare, no studies to date have offered an explicitly spatial analysis of their access to trans-specific care. This study aims to fill that gap by providing a spatial analysis of access to gender-affirming hormone therapy (GAHT) using Texas as a case study. We used the three-step floating catchment area method, which relies on census tract-level population data and location data for healthcare facilities to quantify spatial access to healthcare within a specific drive-time window, in our case 120 min. For our tract-level population estimates we adapt estimates of the rates of transgender identification from a recent data source, the Household Pulse Survey, and use these in tandem with a spatial database of GAHT providers of the lead author's creation. We then compare results of the 3SFCA with data on urbanicity and rurality, as well as which areas are deemed medically underserved. Finally, we conduct a hot-spot analysis that identifies specific areas where health services could be planned in ways that could improve both access to GAHT for trans people and access to primary care for the general population. Ultimately, we conclude that our results illustrate that patterns of access to trans-specific medical care, like GAHT, do not neatly follow patterns of access to primary care for the general population and that therefore trans communities' access to healthcare warrants specific, further investigation.

The Effects of Victim Gender Identity, Juror Gender, and Judicial Instructions on Victim Blaming, Crime Severity Ratings, and Verdicts in Sexual Assault Trials

Transgender individuals may experience social discrimination and unfair legal considerations as crime victims. The current purpose was to investigate the relationship between the participant/jurors' gender, the victims' gender identity, and judge's instructions to ignore the gender identity of the victim on perceptions of the victim and the crime and verdicts rendered in a sexual assault case. Overall, crime severity ratings were significantly lower for the trans male victim compared to the cisgender female victim. Male participants reported lower crime severity ratings for trials involving transgender victims compared to cisgender victims. However, victim blaming, likelihood that the defendant committed the crime, sentencing recommendations, verdict confidence, and conviction rates did not vary by the victim's gender identity, the participant's gender identity, nor the judge's instructions. Participant gender as a predictor of verdict approached significance, indicating a trend for males to render more not guilty verdicts and females to render more guilty verdicts. In summary, male jurors perceived the crimes involving transgender victims as less severe and this may have impacted the rate of not guilty verdicts.

"It's the Environment, Not Me": Experiences shared by transgender and gender diverse adults living in Texas

Transgender and gender diverse people (TGD) experience elevated rates of behavioral health problems, including depression, anxiety, substance misuse, and suicidality. Minority stressors (e.g., discrimination and victimization) contribute to these poor health outcomes. A salient form of discrimination is the use of gender nonaffirming language, such as using incorrect pronouns or names, yet less is known about other environmental stimuli that may be reined as affirming or nonaffirming. A recent study uncovered the impact symbols (e.g., flags, stickers) may have on invoking positive or negative feelings among TGD youth in the Midwest. Our study further investigates this phenomenon with TGD adults in Texas. During Summer 2021, 3 researchers conducted audio-recorded semistructured focus groups and interviews with 11 participants who identified as transgender, gender nonconforming, or nonbinary. Interview topics included gender-affirming and nonaffirming language, positive and negative experiences, nonsupportive and supportive symbolism, and coping mechanisms. In this manuscript, we present findings regarding symbolism. Within our two primary themes, supportive and nonsupportive symbolism, subthemes emerged. Supportive symbolism includes flags and signage, written and oral language and communication, and representation of diversity. Nonsupportive symbolism includes extreme patriotism and religious symbols and highly gendered settings. Further, Texas-specific culture and a meter of safety were identified as being related to interacting with and observing an array of symbols. Symbolism can have a profound impact on someone's identity development, expression, emotions, coping mechanisms, and access to and engagement with social environments, exemplifying the importance of understanding geographic and cultural-specific mechanisms within environments TGD people occupy.

Trans broken arm syndrome: A mixed-methods exploration of gender-related medical misattribution and invasive questioning

RATIONALE

Gender-related medical misattribution and invasive questioning (GRMMIQ), colloquially known as "trans broken arm syndrome," is a form of medical discrimination faced by transgender and gender diverse (TGD) patients wherein a provider incorrectly assumes that a medical condition results from a patient's gender identity or medical transition. This phenomenon may take one of two forms: (1) the incorrect and explicit misattribution of gender identity or medical transition as being the cause of an acute complaint, or (2) invasive and unnecessary questions regarding a patient's gender identity or gender transition status.

OBJECTIVE

Using mixed-methods procedures, this study aims to explore the incidence, some common correlates, and manifestations of GRMMIQ.

METHODS

American TGD participants (N = 147), recruited through an online recruitment platform, completed questions assessing their experiences in the healthcare system including lifetime incidence of GRMMIQ, outness to healthcare providers, and additional experiences of gender-related discrimination in a medical setting. Participants who indicated experiences of GRMMIQ were asked open-ended questions about one such experience.

RESULTS

Nearly one-third of participants reported experiencing GRMMIQ. Experiences were associated with outness to acute care providers and other types of gender-related discrimination in healthcare settings. Analysis of qualitative data revealed four primary themes: (1) assumptions of disordered thinking and being, (2) hyperfocus on aspects of medical transition, (3) cultural ignorance and incompetence, and (4) dismissiveness of the patient.

CONCLUSION

Together, these results enhance the understanding of an underexplored aspect of medical discrimination faced by TGD individuals while highlighting commonalities across different experiences.

The measurement of gender expression in survey research

Previous research on the survey measurement of sexual orientation, gender identity, and gender expression (SOGIE) often focuses on the measurement of identity, with comparably little research focused on gender expression as a key feature of how gender is lived and experienced. This study examines the reliability and validity of survey questions about gender expression in a 2-by-5-by-2 factorial experiment that varies the question order, type of response scale, and the order of gender presentation in the response scale. The results indicate that the effect of which (side of the) scale is presented first on gender expression varies by gender for each of the unipolar items and one of the bipolar items (behavior). In addition, the unipolar items also show distinctions among the gender minority population in ratings of gender expression as well as more nuance with respect to concurrent validity in predicting health outcomes among cisgender respondents. The results of this study have implications for researchers who are interested in accounting for gender holistically in survey and health disparities research.

When are trans women treated worse than trans men?

Purpose

This paper aims to test penis panic theory, which predicts that trans women will face more discrimination than trans men in some but not all situations.

Design/methodology/approach

Respondents were 262 American college students who were all enrolled in the same undergraduate course. They were presented with a case about coworker resistance to transgender employees' use of the workplace restrooms of their choice. Four versions of a case were randomly distributed as follows: trans woman, restroom with one toilet; trans woman, restroom with three toilets; trans man, restroom with one toilet and trans man, restroom with three toilets.

Findings

The authors observed greater discrimination against trans women compared to trans men when there was one toilet but not when there were three toilets. This supports penis panic theory.

Research limitations/implications

The chief limitation was the use of American college students as respondents. The results may not generalize to practicing managers especially in other countries. Future researchers should develop a scale to measure situational discrimination against trans women. This study should be replicated in other contexts to deepen the understanding of discrimination against trans men and trans women with disabilities, as well as discrimination against nonbinary individuals who identify as neither trans men nor trans women.

Practical implications

Employers need to search for situations in which trans women face greater discrimination than trans men, because they can be resolved in ways that protect the rights of transgender employees no matter how transphobic their coworkers may be. Also, employers need a nuanced approach to combat discrimination that recognizes the unique perspectives of trans men, trans women and other members of the transgender community.

Originality/value

This is the first quantitative study of penis panic theory, and it illuminates the understanding of discrimination against transgender individuals.

Operationalization of a multidimensional sex/gender concept for quantitative environmental health research and implementation in the KORA study: Results of the collaborative research project INGER

Background

In environmental health research, sex and gender are not yet adequately considered. There is a need to improve data collection in population-based environmental health studies by comprehensively surveying sex/gender-related aspects according to gender theoretical concepts. Thus, within the joint project INGER we developed a multidimensional sex/gender concept which we aimed to operationalize and to test the operationalization for feasibility.

Methods

In an iterative process, we created questionnaire modules which quantitatively captured the requirements of the INGER sex/gender concept. We deployed it in the KORA cohort (Cooperative Health Research in the Region of Augsburg, Germany) in 2019 and evaluated response and missing rates.

Results

The individual sex/gender self-concept was surveyed via a two-step approach that asked for sex assigned at birth and the current sex/gender identity. Additionally, we used existing tools to query internalized sex/gender roles and externalized sex/gender expressions. Adapted to the KORA population, we asked for discrimination experiences and care and household activities contributing to explain structural sex/gender relations. Further intersectionality-related social categories (e.g., socio-economic position), lifestyle and psychosocial factors were covered through data available in KORA. We could not identify appropriate tools to assess the true biological sex, sexual orientation and ethnic/cultural identity, which have yet to be developed or improved. The response-rate was 71%, the evaluation of 3,743 questionnaires showed a low missing rate. Prevalence of marginalized groups regarding sex/gender identity and definable by experiences of discrimination was very low.

Conclusion

We have shown how the multidimensional INGER sex/gender concept can be operationalized according to an European and North American understanding of sex/gender for use in quantitative research. The questionnaire modules proved feasible in an epidemiologic cohort study. Being a balancing act between theoretical concepts and its quantitative implementation our operationalization paves the way for an adequate consideration of sex/gender in environmental health research.

Outness, Discrimination, and Psychological Distress Among LGBTQ+ People Living in the Southern United States

Purpose: Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people face mental health disparities. These disparities are amplified in the Southern regions of the United States. This study assessed the role of outness, discrimination, and other demographic variables on possible serious mental illness (SMI) among LGBTQ+ Southerners. Methods: This study used data from the 2017 LGBT Institute Southern Survey, a cross-sectional convenience sample of 6502 LGBTQ+ adults living in 14 Southern states. Multivariable logistic regression was performed to examine differences between those with and without possible SMI. Results: Outness was associated with a lower likelihood of possible SMI (odds ratio [OR]: 0.696, 95% confidence interval [CI]: 0.574-0.844, p = 0.001), especially when controlling for discrimination in the past 12 months (OR: 0.693, 95% CI: 0.576-0.834, p ≤ 0.001) and lifetime discrimination (OR: 0.678, 95% CI: 0.554-0.829, p = 0.001). Lifetime discrimination was associated with a higher likelihood of possible SMI (OR: 1.413, 95% CI: 1.034-1.932, p = 0.033), as was discrimination experienced in the past 12 months (OR: 1.626, 95% CI: 1.408-1.877, p ≤ 0.001). Black/African American respondents had the lowest percentage of possible SMI (21.0%) compared with other races, despite having lower or comparable rates of outness. Conclusion: These results indicate a possible promotive effect of outness against possible SMI among LGBTQ+ Southerners, as well as possible promotive group-level factors among Black/African American LGBTQ+ Southerners. Policies and interventions that address discrimination against LGBTQ+ Southerners should be expanded, and future research should address how the relationships between outness, discrimination, and mental health outcomes may vary by subgroup.

Mindfulness Meditation Programs Informed by Transgender Youth

Objectives

This study explores the openness of transgender and gender diverse youth and young adults (TGDY) to mindfulness meditation programs in order to create culturally informed interventions to benefit this population.

Method

Two focus groups were conducted with a total of ten TGDY ages 14-24 years old at a transgender youth health center in a large metropolitan city in the USA. A 10-min guided mindfulness meditation was included for participants to experience and voice reactions to. The State-Trait Anxiety Inventory (STAI) was utilized to measure the quantitative impact of the meditation on participants' anxiety and thematic analysis for the qualitative data.

Results

Reflexive Thematic Analysis on qualitative focus group data revealed the following four themes: Active in Self-care, Silent Meditation Is "Not for Me," Guided Mindfulness Calms and Connects, and Program Ideas for Future. STAI results indicated a statistically significant reduction in anxiety following participation in the group meditation.

Conclusions

Participants were open to mindfulness as an additional method of self-care, and they emphasized future programs should include sensory stimulation, a pressure-free environment accepting of active minds and bodies, and a transgender instructor if possible. Meditation and mindfulness have the potential to be a very powerful healing modality for TGDY in clinical and therapeutic care.

Preregistration

This study is not preregistered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-022-02048-6.

Exploring Transgender and Gender Diverse Young Adult Tobacco Use

Aside from prevalence estimates and comparisons to heterosexual and presumed cisgender (i.e., not transgender) samples, little is known about transgender and gender diverse (TGD) young adult tobacco use. This study explored reasons and contexts TGD young adults used a variety of tobacco products through 25 one-on-one semi-structured qualitative interviews in 2018. Thematic analysis yielded four themes: (1) smoking in response to anxiety, depression, or stress, (2) social smoking, (3) accepting smoking-related norms, and (4) appealing aspects of tobacco. The first three themes contained elements specifically tied to TGD identity; the final theme related to perceptions of tobacco unrelated to identity. Findings suggest reasons for smoking that are unique to TGD young adults, who frequently reported smoking cigarettes as a coping response to an amalgam of stressors. Accounting for unique stressors related to TGD identity will assist in developing culturally relevant interventions to reduce the disproportionate tobacco burden in TGD communities.

An Analogue Study Investigating Differential Parenting of Gender Conforming and Nonconforming Boys

Gender nonconforming children are at heightened risk for negative parenting interactions. This study investigated possible explanations for differences in parenting behaviors with gender conforming and nonconforming boys. A sample of 201 adults (43% women/57% men; 81% White, 10% Black/African American, 6% Multiracial, 3% Asian, and 1% American Indian or Alaska Native; and 7% Hispanic/Latinx) ranging in age from 20 to 74 years (M = 35.44, SD = 9.76) were presented two vignettes describing a gender conforming and nonconforming boy. Following each vignette, participants provided endorsements of parenting behaviors and reported their concern for that child's future. In addition, participants completed measures assessing their attitudes toward homosexuality and need for closure. Contrary to expectations, there were no significant differences in endorsements of physical discipline or positive parenting for the two boys. Participants did, however, report higher concern for the gender nonconforming boy's future. Individual differences in homonegativity were associated with greater endorsements of physical discipline toward the gender nonconforming boy, after accounting for endorsements of physical discipline toward the gender conforming boy. Further, higher concern for the gender nonconforming boy's future was associated with greater endorsements of physical discipline and lower endorsements of positive parenting, after accounting for endorsements of each behavior for the gender conforming boy as well as concern for their future. Intervention efforts to support the parent-child relationship for gender nonconforming boys may benefit from identifying and responding to both negative attitudes toward homosexuality and addressing motivations to change behavior resulting from concern for their child's future.

Heterogeneity in the Desire to Undergo Various Gender-Affirming Medical Interventions Among Transgender People in Hong Kong: Findings from a Community-Driven Survey and Implications for the Legal Gender Recognition Debate

Previous estimates suggest that there are at least nine million transgender people in Asia-Pacific; however, in most countries, legal gender recognition has not been made possible or there are otherwise stringent eligibility criteria. The obligation of having undergone gender-affirming medical interventions as a basis for such recognition is being hotly debated. However, there has been little empirical evidence on the desire to undergo various gender-affirming medical interventions among transgender people. This study fills the research gap by studying Hong Kong, where a transgender person must produce medical evidence for "complete" sex reassignment surgery in order to change the sex entry on their identity card. A community-driven survey of 234 transgender people found that only 13.0% of the participants who were assigned male at birth could fit such a requirement. Strikingly, because none of the participants assigned female at birth had undergone construction of a penis or some form of a penis, all of them would be excluded from legal gender recognition. Financial reasons and reservations about surgical risks and/or techniques were the most commonly cited reasons for not undertaking the medical interventions. The findings suggest that an overwhelming majority of transgender people in Hong Kong are excluded from legal gender recognition, which fundamentally affects their civil, political, economic, social, and cultural rights. More generally, this study shows heterogeneity among transgender people in the desire for different gender-affirming medical interventions, and thus argues that the legal gender recognition debate needs to consider their concerns and self-determination.

Intersectionality and the invisibility of transgender health in the Philippines

Transgender (trans) Filipinos are disproportionately vulnerable to health problems because of the inaccessibility of essential healthcare services resulting from the invisibility and exclusion of trans health in Philippine health and related social institutions. Because of the institutional prejudice and discrimination against trans Filipinos in Philippine society, an intersectional approach presents an opportunity to analyze the invisibility and potentially elucidate the unique health needs of trans Filipinos. This article elucidates how the invisibility of trans Filipinos in health is a product of co-existing and interacting prejudiced and discriminatory institutions, such as the law, education, and medicine, where the historical experiences of colonization, the hegemony of cisgenderism, and the impact of capitalism remain salient. By elucidating these co-existing and interacting structures and forces, this article highlights the gaps in the Philippine healthcare system, such as the lack of affirming and protective policies for trans health and the limited cultural competence of healthcare providers. In light of these, future research and policy work must work towards integrating gender-specific and gender-inclusive approaches, centering the voices of trans Filipinos in health discourses, and decolonizing and expanding the local understanding of trans health among Filipinos.

State-Level Policy Environments, Discrimination, and Victimization among Sexual and Gender Minority People

Legislation has been passed in some states to reduce discrimination and victimization toward sexual and gender minority people (SGM; people who are not solely heterosexual and/or whose gender identity is not equal to what is socially associated with sex assigned at birth). The purpose of these analyses is to test whether state-level policy environments are associated with past-year discrimination and victimization among SGM people. Cross-sectional data from The Population Research in Identity and Disparities for Equality (PRIDE) Study annual questionnaire (collected 2018−2019), a national study of the health of SGM adults in the USA, were used for these analyses. Measures included related to discrimination, victimization, and demographic characteristics. State-level policy environments were measured using data from the Movement Advancement Project. Logistic regression analyses evaluated state-level policy environment scores and past-year discrimination and victimization among gender identity categories. In this sample, 7044 people (gender minority n = 2530) were included. Cisgender sexual minority (odds ratio [OR] = 1.007, p = 0.041) and the gender expansive subgroup of gender minority people (OR = 1.010, p = 0.047) in states with more protective policy environments had greater odds of discrimination. The gender expansive subgroup was found to have greater odds of victimization in states with more protective policy environments (OR = 1.003, p < 0.05). There was no relationship between state-level policy environments and victimization among any other study groups. SGM people may experience increased risk for discrimination and victimization despite legislative protections, posing continued risks for poor health outcomes and marginalization. Evaluation of factors (e.g., implementation strategies, systems of accountability) that influence the effectiveness of state-level polices on the reported experiences of discrimination and victimization among SGM people is needed.

Is being gender nonconforming distressing? It depends where you live: gender equality across 15 nations predicts how much gender nonconformity is related to self-esteem

BACKGROUND

Individuals exhibiting gender nonconforming behaviors experience low self-esteem and a number of other mental health conditions, including elevated suicide risk. Most of the relevant evidence is confined to US studies, however. Adopting a cross-national approach, we examined the pervasiveness of the psychological burden associated with gender nonconformity. Because self-esteem is sensitive to the fulfillment of societal expectations for gender conformity, we reasoned that the relationship between gender conformity and self-esteem ought to decrease as societies become less restrictive in their gender norms.

METHODS

To test this proposition, we conducted two studies including 18 national samples from 15 countries varying in gender equality. Participants responded to an online survey that included measures of gender conformity and self-esteem (N = 4486).

RESULTS

Using multilevel analyses and meta-analytic statistics over the samples of both studies, we found that as gender equality increased, the association between gender conformity and self-esteem decreased.

CONCLUSIONS

The results suggest that rather than being inherently noxious, gender non-conformity becomes detrimental to self-esteem when it clashes with restrictive gender role norms that are enacted by the macrosocial context. We suggest that previous findings on psychological problems related to gender nonconformity be considered within a broader macrosocial context that may constrain people's freedom to move against gender role norms.

Differences in All-Cause Mortality Among Transgender and Non-Transgender People Enrolled in Private Insurance

Few studies have analyzed mortality rates among transgender (trans) populations in the United States and compared them to the rates of non-trans populations. Using private insurance data from 2011 to 2019, we estimated age-specific all-cause mortality rates among a subset of trans people enrolled in private insurance and compared them to a 10% randomly selected non-trans cohort. Overall, we found that trans people were nearly twice as likely to die over the period as their non-trans counterparts. When stratifying by gender, we found key disparities within trans populations, with people on the trans feminine to nonbinary spectrum being at the greatest risk of mortality compared to non-trans males and females. While we found that people on the trans masculine to nonbinary spectrum were at a similar risk of overall mortality compared to non-trans females, their overall mortality rate was statistically smaller than that of non-trans males. These findings provide evidence that some trans and non-trans populations experience substantially different mortality conditions across the life course and necessitate further study.

Intimate Partner Violence Help-Seeking in the U.S. Transgender Survey

Research finds that transgender survivors of intimate partner violence (IPV) often face transphobia-related barriers to reaching help. Due partially to a dearth of larger datasets supporting multivariate analyses, it is unclear whether sociodemographic factors can further hinder transgender help-seeking. Addressing these gaps, logistic regression secondary data analyses were conducted with 15,198 transgender IPV survivors from the nationally-representative 2015 U.S. Transgender Survey. Odds of seeking help from survivor agencies were significantly greater for survivors who are trans men, assigned-female-at-birth genderqueer, Alaska Native or American Indian, poorer, transphobia victims, and victims of any IPV type, especially controlling IPV. In addition, odds of not seeking help due fearing transphobic responses were significantly greater for survivors who are trans women, asexual or bisexual, poorer, younger, undocumented, childless, ever homeless, transphobia victims, or victims of any IPV type, particularly sexual IPV. Implications for future research and population-specific service provision are discussed.

Explicit and Implicit Gender-Related Stereotyping in Transgender, Gender Expansive, and Cisgender Adults

Little is known about gender-related stereotyping among transgender and gender expansive adults. Using the Ambivalent Sexism Inventory (AIS; Glick & Fiske, 1996), we examined explicit gender attitudes in 3298 cisgender, transgender, and gender expansive respondents designated female at birth (FAB; n = 1976 cisgender, n = 108 transgender, n = 188 gender expansive) and male at birth (MAB; n = 922 cisgender, n = 52 transgender, n = 52 gender expansive). In order to learn more about implicit gender-related stereotyping, a subset of 822 participants (FAB; n = 445 cisgender, n = 32 transgender, n = 51 gender expansive. MAB; n = 254 cisgender, n = 21 transgender, n = 19 gender expansive) completed the gender-leadership Implicit Association Test (IAT; Dasgupta & Asgari, 2004). Cisgender men scored significantly higher than all other groups on hostile sexism, but patterns of endorsement for benevolent sexism and implicit attitudes were more nuanced, with cisgender women and gender expansive FAB often scoring significantly below other groups. We observed that transgender men and transgender women, along with cisgender men and gender expansive MAB, moderately endorsed essentialist views regarding differences between men and women (i.e., complementary gender differentiation). These data reveal novel patterns of gender-related stereotyping, with some corresponding to sex designated at birth and others corresponding to current gender identification. Together, these findings suggest that one's experienced gender, designated sex at birth, and the intersection between them may relate to gender stereotyping, underscoring the importance of including transgender and gender expansive individuals in this research.