Autopsy of a failed trial part 2: Outcomes, challenges, and lessons learnt from the DAISIES trial

OBJECTIVE

The relative merits of inpatient or day-treatment for adults with anorexia nervosa (AN) are unknown. The DAISIES trial aimed to establish the non-inferiority of a stepped-care day patient treatment (DPT) approach versus inpatient treatment as usual (IP-TAU) for improving body mass index (BMI) at 12 months in adults with AN. The trial was terminated due to poor recruitment. This paper presents outcomes and investigates the reasons behind the trial's failure.

METHOD

Fifteen patients with AN (of 53 approached) participated and were followed-up to 6 or 12 months. Summary statistics were calculated due to low sample size, and qualitative data concerning treatment experiences were analysed using thematic analysis.

RESULTS

At baseline, participants in both trial arms rated stepped-care DPT as more acceptable. At 12 months, participants' BMIs had increased in both trial arms. Qualitative analysis highlighted valued and challenging aspects of care across settings. Only 6/12 sites opened for recruitment. Among patients approached, the most common reason for declining participation was their treatment preference (n = 12/38).

CONCLUSIONS

No conclusions can be drawn concerning the effectiveness of IP-TAU and stepped-care DPT, but the latter was perceived more positively. Patient-related, service-related and systemic factors (COVID-19) contributed to the trial's failure. Lessons learnt can inform future studies.

Transition support for patients admitted to intensive treatment for anorexia nervosa: qualitative study of patient and carer experiences of a hybrid online guided self-help intervention (ECHOMANTRA)

BACKGROUND

Adults with anorexia nervosa experience high levels of relapse following in-patient treatment. ECHOMANTRA is a novel online aftercare intervention for patients and carers, which provides psychoeducation and support to augment usual care.

AIMS

To explore patient and carer experiences of receiving the ECHOMANTRA intervention.

METHOD

This is part of the process evaluation of the ECHOMANTRA intervention as delivered in the TRIANGLE trial (ISRCTN: 14644379). Semi-structured interviews were conducted with 20 participants randomised to the ECHOMANTRA (ten patients and ten carers). Thematic analysis was used to analyse the interview transcripts.

RESULTS

Five major themes were identified: (1) Mixed experience of the intervention; (2) tailoring the intervention to the stage of recovery; (3) involvement of carers; (4) acceptability of remote support; and (5) impact of self-monitoring and accountability.

CONCLUSIONS

Participants were mostly positive about the support offered. The challenges of using remote and group support were counterbalanced with ease of access to information when needed. Components of the ECHOMANTRA intervention have the potential to improve care for people with eating disorders.

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.

Assessment and treatment of compulsive exercise in anorexia nervosa - A combined investigation of Compulsive Exercise Activity Therapy (LEAP) and Compulsive Exercise Test subscales

INTRODUCTION

Compulsive exercise is a transdiagnostic feature of eating disorders which adversely affects aspects of recovery, such as length of hospitalisation, risk of a chronic outcome, and risk of relapse. CompuLsive Exercise Activity TheraPy (LEAP) aims to reduce compulsive exercise through a cognitive behavioural approach. This study aims to investigate the effect of LEAP on compulsive exercise behaviour using subscales of the Compulsive Exercise Test (CET), a measure of exercise in individuals with eating disorders. Predictive validity of the CET's subscales and its ability to predict eating psychopathology are investigated.

METHOD

This study used data from a randomized controlled trial of LEAP (1). Linear mixed modelling was used to investigate the effect of LEAP on compulsive exercise behaviour, and the predictive ability of CET subscales on various outcomes. The CET was compared to other exercise measures to assess its superiority in predicting eating psychopathology.

RESULTS

LEAP was superior in reducing the scores of the CET's Avoidance and Rule Driven Behaviour and Exercise Rigidity subscales. All subscales made a contribution to the respective models. The CET was superior to other measures in predicting eating pathology.

CONCLUSION

The results lend credibility to LEAP's ability to reduce core parts of compulsive exercise. The CET has been found to target important aspects of compulsive exercise behaviour, and has was superior to other exercise measures in predicting eating psychopathology.

An intervention mapping adaptation framework to develop a self-help intervention for athletes with eating disorder symptoms

OBJECTIVE

This research forum describes the use of the intervention mapping for adaptation (IMA) framework to develop and evaluate a novel intervention for athletes with mild eating disorder (ED) symptoms.

METHODS

The six IMA steps were followed. In step 1 (needs assessment), we conducted a systematic review of athlete ED interventions and held interviews/focus groups with athletes and sports professionals to inform intervention format and delivery. In step 2 (intervention search), needs assessment information guided the search for an evidence-based intervention suitable for adaptation to athletes. In steps 3 and 4 (intervention development), the identified intervention was adapted and feedback sought from athletes and sport professionals. In steps 5 and 6 (implementation and evaluation), a feasibility study was conducted with athletes (n = 35; females: n = 27; Mage  = 27.1).

RESULTS

The review highlighted poor evidence for the acceptability and relative efficacy of existing interventions, which were all delivered face-to-face in groups. Interview/focus group data suggested a need for more accessible intervention formats (e.g., self-help). One non-athlete self-help intervention was determined suitable for adaptation to athletes, and adaptations were made. Initial feedback suggested the adapted intervention was relevant within sport settings. The feasibility study revealed that the intervention (MOPED-A: Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms) can be feasibly implemented, is acceptable to athletes and shows potential for reducing ED symptoms.

DISCUSSION

IMA is a useful framework for developing participant-centered and evidence-based interventions. The findings and approach taken provide a framework for other researchers and clinicians in developing similar interventions in the ED domain.

PUBLIC SIGNIFICANCE

The novel self-help intervention described in this article was developed using intervention mapping and provides promise as a tool for reducing eating disorder symptoms in athletes. We describe how adopting and systematically following a health intervention development approach, such as intervention mapping, can ensure that eating disorder interventions are participant-centered, contextually relevant, and evidence-based, which in turn could help to maximize their reach and effectiveness.

Impact of LEAP and CBT-AN Therapy on Improving Outcomes in Women with Anorexia Nervosa

Anorexia nervosa (AN) is a mental health disorder that has serious physical, emotional and social consequences. Whilst cognitive behavioural therapy for AN (CBT-AN) has demonstrated efficacy, there remains a global need to improve AN treatment. Compulsive exercise activity therapy (LEAP) is an active therapy consisting of the addition to CBT-AN of eight specific sessions that focus on exercise and motivation for behavioural change. This paper presents a secondary analysis of 74 female participants in a randomised control trial of LEAP plus CBT-AN versus CBT-AN alone. The main aim of this study was to explore putative predictors and to estimate the magnitude of changes due to LEAP for specific outcome measures. Participants (LEAP: n = 36; CBT-AN: n = 38) were assessed at three successive surveys: baseline, end of therapy, and 6 months post-therapy. The overall effect sizes for changes between baseline to end of therapy and baseline to 6-month follow-up assessment showed large effect sizes (Cohen's d > = 0.80) for mental-health-related quality of life (MHRQoL), weight concern, dietary restraint, eating concern, AN stage change, and psychological distress (all p < 0.05). The results also indicated that several pre-treatment characteristics, including body mass index (BMI), level of eating disorder (ED) symptoms, and MHRQoL are important for identifying whether a treatment is likely to be effective. Future treatment programs should aim to optimise early improvements in BMI, ED symptoms, and MHRQoL.

Autopsy of a failed trial part 1: A qualitative investigation of clinician's views on and experiences of the implementation of the DAISIES trial in UK-based intensive eating disorder services

OBJECTIVE

The DAISIES trial, comparing inpatient and stepped-care day patient treatment for adults with severe anorexia nervosa was prematurely terminated in March 2022 due to poor recruitment. This qualitative study seeks to understand the difficulties faced during the trial by investigating stakeholders' views on and experiences of its implementation.

METHOD

Semi-structured interview and focus group transcripts, and trial management and oversight group meeting minutes from May 2020-June 2022 were analysed using thematic analysis. Participants were 47 clinicians and co-investigators involved with the DAISIES trial. The Non-Adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework was applied to the interpretive themes to classify barriers and facilitators to implementation.

RESULTS

Five themes were identified: incompatible participation interests; changing standard practice; concerns around clinical management; systemic capacity and capability issues; and Covid-19 disrupting implementation. Applying the NASSS framework indicated the greatest implementation challenges to arise with the adopters (e.g. patients, clinicians), the organisational systems (e.g. service capacity), and the wider socio-political context (e.g. Covid-19 closing services).

CONCLUSIONS

Our findings emphasise the top-down impact of systemic-level research implementation challenges. The impact of the Covid-19 pandemic accentuated pre-existing organisational barriers to trial implementation within intensive eating disorder services, further limiting the capacity for research.

Nonbinary gender identities

A description of the meaning and terminology as well as population estimates of nonbinary gender identities is given. Respectful use of language, names and pronouns of people who identify as nonbinary is discussed. The chapter further includes the need for access to gender-affirming care and barriers to care; gender-affirming medical treatment interventions, including hormone treatment, speech and language therapy, hair removal and surgeries for bodies assigned female at birth (AFAB) and for bodies assigned male at birth (AMAB); and the importance of fertility preservation for this specific patient population.

‘I Didn’t Have the Language Then’—A Qualitative Examination of Terminology in the Development of Non-Binary Identities

Introduction: Identities that lie outside of exclusively male and female, such as non-binary and genderqueer, have become increasingly more prevalent and visible within recent years. However, to date, the role of terminology in the development of such gender identities has been under-researched. This study aims to: (1) Examine what role terminology plays in coming to identify as non-binary. (2) Explore the continuing importance of terminology once a non-binary identity is established. Methods: This study uses thematic analysis on data produced from interviews with 16 participants who self-selected for the study and were recruited from several transgender and LGBTQ+ organisations on the basis that they identified outside the gender binary of male and female. Results: The analysis uncovered several key themes and sub-themes relating to terminology choice, encountering new terms and the process of identifying with new terminology, as well as becoming visible and understood by others. Conclusions: This study found that terminology is not only central in coming to identify as something other than exclusively male and female, it also remains an important factor when it comes to making a non-binary identity visible to others.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers

BACKGROUND

Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge.

AIMS

The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community.

METHOD

Semi-structured interviews were conducted with patients with anorexia nervosa (n = 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (n = 20). Data were analysed with inductive thematic analysis.

RESULTS

Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process.

CONCLUSIONS

The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.

The clinical effectiveness and cost-effectiveness of a 'stepping into day treatment' approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial

Background

Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a ‘step-down’ treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation.

Methods

386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m² and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden.

Discussion

The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision.

Trial registration

ISRCTN ISRCTN10166784. Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has significantly affected intensive treatment settings (i.e., inpatient [IP] and day patient [DP]) in specialist eating disorder services. However, the impact on clinicians working in these services is largely unknown. We therefore explored the perspectives of those supporting individuals with severe anorexia nervosa (AN) in intensive treatment settings during the pandemic.

METHODS

Between May 2020 and June 2021, we interviewed clinicians (n = 21) who delivered IP and/or DP treatment to patients with severe AN in four specialist eating disorder services in the United Kingdom. Data relating to experiences during COVID-19 were analysed using reflexive thematic analysis.

RESULTS

We identified six themes: Disruptions to Routine Treatment; Introduction of Virtual Treatment; Separation from Treatment, Others and the World; Impact on Recovery; Impact on Staff; and Pressure on Referral Pathways. COVID-19 posed significant challenges to IP and DP services: forcing closures, operating with restrictions and virtual treatment, and impacting delivery of essential treatment components, referral pathways, clinician wellbeing, risk management, and patient isolation and recovery trajectories. Opportunities arose, in particular in DP services offering virtual support.

CONCLUSIONS

COVID-19 challenged the continuation of multidisciplinary treatment. The findings underline the necessity for medical, psychological, practical, and nutritional support, as well as carer involvement and fostering social connections to remain at the forefront of intensive treatment for severe AN. They also emphasise the uncertainty surrounding which intensive treatment may be best suited to which patient when, particularly within the context of virtual DP support.

Evaluating a motivational and psycho-educational self-help intervention for athletes with mild eating disorder symptoms: A mixed methods feasibility study

Objective

The primary aim was to assess the feasibility of undertaking a study evaluating the novel Motivational and Psycho‐Educational Self‐Help Programme for Athletes with Mild Eating Disorder Symptoms (MOPED‐A). A mixed‐methods approach was adopted to explore the feasibility of recruiting and retaining participants, and to evaluate the acceptability of measures, procedures and the intervention. A secondary aim was to explore the potential efficacy of MOPED‐A in reducing athletes' eating disorder symptoms.

Method

Thirty‐five athletes were recruited. Participation involved completing MOPED‐A over a 6‐week period and completing self‐report measures at baseline (T1), post‐intervention (T2) and 4‐week follow‐up (T3). A subsample (n = 15) completed an interview at T2.

Results

Retention was good throughout the study (n = 28; 80%). Quantitative and qualitative feedback suggested the format, delivery, content and dosage of MOPED‐A were acceptable. Athletes valued that the intervention was tailored to them, and this facilitated both participation and completion. Over a third of participants reported disclosing their eating difficulties and deciding to seek further support. Large reductions in eating disorder symptoms were detected at T2 and sustained at T3.

Conclusions

The MOPED‐A intervention can be feasibly implemented, is acceptable to participants, and demonstrates potential for reducing symptoms in athletes. A larger, controlled trial is warranted.

Participant recruitment to the study was feasible, and an acceptable proportion of participants were retained throughout the study.

This is the first study to show that the format and delivery of a self‐help intervention is acceptable to athletes with mild eating disorder symptoms, and that athletes valued the intervention being tailored to them which facilitated participation and completion.

The intervention demonstrates potential for reducing athletes' eating disorder symptoms.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings

BACKGROUND

Admissions to intensive treatment (i.e., inpatient [IP] and/or day patient [DP]) for individuals with severe anorexia nervosa (AN) are common. Growing literature indicates potential risks and benefits of each intensive treatment approach; however, existing research has focused on patient and carer perspectives of these treatments. Also, there is scant empirical evidence available for guiding the parameters of intensive treatments for AN. We therefore explored clinicians' perspectives and experience of supporting adults with severe AN in intensive settings.

METHODS

We conducted twenty one semi-structured interviews with clinicians who deliver intensive treatments (i.e., IP and/or DP) for individuals with severe AN across four specialist Eating Disorder Services in the United Kingdom between May 2020 and June 2021. We asked clinicians about their views and experiences of supporting individuals with severe AN in intensive treatment settings and the challenges and opportunities associated with IP and DP treatment. Data were analysed using reflexive thematic analysis supported by NVivo software.

RESULTS

Five broad and interrelated themes were identified: (1) Intensive Support; (2) The Severity of Patients' Illnesses; (3) Hope and Recovery; (4) Which Treatment When; (5) Limited Resources; and (6) Carer Burden. We identified various similarities between the two intensive treatment approaches, including the value of intensive and multidisciplinary support and carer involvement, and the challenge of managing complex and unique needs in resource-limited intensive settings. We also found differences in the relationship of treatment to patients' home environments, the necessity of patient motivation, and the management of risk.

CONCLUSIONS

Both intensive treatment settings are valued by clinicians; however, there are unique challenges and opportunities for supporting individuals with severe AN within each. Our findings suggest DP treatment may be used as an alternative to IP treatment for individuals with severe AN. However, clear questions remain over which intensive treatment setting is best suited to which patient when and should be the focus of future research.

Feasibility and acceptability of experience sampling among LGBTQ+ young people with self-harmful thoughts and behaviours

This study was the first to determine whether it was feasible and acceptable to use experience sampling methods (ESM) among LGBTQ+ young people, who had current experiences of self-harm. Sixteen LGBTQ+ young people (16-25 years old) took part in the experience sampling study. This included a baseline assessment, a 7-day ESM assessment (participants were sampled six times a day using a phone app), and the option of an interview at the end of the 7-day ESM assessment. Feasibility data was descriptively analysed, with pilot ESM data presented. Qualitative data was thematically analysed to determine the acceptability (barriers and facilitators) of taking part in this study. Study feasibility was assessed by enrolment rate (55.2%), participant retention across assessment period (100%), ESM app feasibility (87.5%), and good adherence to total number of ESM surveys (67.6%). Individual study adherence ranged between 43 and 95.2%. Study acceptability was assessed by participant interviews. Thematic analysis indicated four superordinate themes; (i) Self-reflection and awareness; (ii) Practicalities of ESM surveys; (iii) Daily timeframes; and (iv) Suggestions for future studies. Pilot ESM data demonstrates that there was fluctuation of depressive and anxiety symptoms within- and between- participants over the course of the study, however, greater sample power is needed for full analysis. This study demonstrated that ESM designs are feasible and acceptable among LGBTQ+ young people with current experiences of self-harm. Pilot data indicated that specific experiences and moods are likely to be important to self-harm. These potentially have a temporal influence on self-harm behaviour or ideation, and therefore should be examined in a fully powered sample.

Understanding the processes underlying self-harm ideation and behaviors within LGBTQ+ young people: A qualitative study

OBJECTIVE

This study aims to understand the processes underlying self-harmful thoughts and behaviors, with and without suicidal intent, among LGBTQ+ young people.

METHOD

Nineteen semi-structured interviews took place between October 2019 and May 2020. Participants were aged between 16 and 25 years, had experiences of self-harm ideation and behaviors, and were part of the LGBTQ+ umbrella. A range of sexualities and gender identities were represented: eleven participants were cisgender, six were transgender and two were non-binary. Interviews were transcribed verbatim and anonymised. Thematic analysis and reflective member-checking were used to develop a thematic framework.

RESULTS

Three themes were developed from the interviews and evaluated by four participants who engaged with reflective member-checking. Findings indicated that internal processes and external responses to being LGBTQ+ resulted in self-harmful thoughts and behaviors. Alongside these, additional stressors related to being a young person were led to difficulties with self-harm.

CONCLUSIONS

Findings from this study indicate that young people often struggle with accepting their LGBTQ+ identity for a number of reasons, whether this is due to access to a resource or their own feelings about their identity. These negative self-perceptions can be enhanced by poor responses from others and additional life stressors which impact their self-esteem or self-perception.HIGHLIGHTSUnderstanding and accepting that one is LGBTQ+ is not always a simple process, struggling with these thoughts can influence self-harm.Lack of LGBTQ+ terminology hinders self-acceptance and caused young people to engage with self-harm.Peers and family members responses to a young people's LGBTQ+ identity is highly significant and can directly led to self-harmful thoughts and experiences.

Identifying coping strategies used by patients at a transgender health clinic through analysis of free-text autobiographical narratives

BACKGROUND

This paper presents an analysis of 32 narratives written by patients waiting for assessment at a transgender health clinic (THC) in England. Narratives are autobiographical free texts, designed to allow patients to describe in their own words their experiences of their gender identity and/or transition prior to a clinic appointment, as part of the assessment process.

OBJECTIVE

Narratives were analysed to identify actions prospective patients had taken to manage their (usually lengthy) waiting times, so that these 'coping strategies' could be shared with future patients.

DESIGN

Corpus linguistic methodology was utilized to identify common patterns across the whole corpus of text-based data, augmented with more detailed sociolinguistic analysis of individual narratives.

RESULTS

There are broad commonalities in the way the transition experience is described across the corpus in terms of presentation of key experiences and feelings. There are specific descriptions of a number of recurring coping strategies, both positive and negative.

CONCLUSION

The empowerment value of writing these narratives may be limited; the existence of recurring key features suggests that patients may feel they have to present their experiences in certain ways to be accepted for treatment. However, dissemination of some positive coping strategies may help future clients of THCs to better cope with waiting times, as well as assisting practitioners in THCs in supporting their patients during this wait.

PATIENT/PUBLIC CONTRIBUTION

The clinic's Service Users' Research Advisory Group contributed to formulating the objective and design of the study. Results were presented at the clinic's annual PPI conference.

A systematic review and meta-analysis of victimisation and mental health prevalence among LGBTQ+ young people with experiences of self-harm and suicide

BACKGROUND

LGBTQ+ youth have higher rates of self-harm and suicide than cisgender, heterosexual peers. Less is known about prevalence of risks within these populations.

OBJECTIVES

The first systematic review and meta-analysis to investigate the prevalence of risks among young people throughout the LGBTQ+ umbrella with experiences across the dimension of self-harm, suicidal ideation and suicide behaviour; and how they may differ between LGBTQ+ umbrella groups.

DATA SOURCES

MEDLINE, Scopus, EMBASE, PsycINFO, and Web of Science searches were run to identify quantitative research papers (database inception to 31st January, 2020).

STUDY ELIGIBILITY CRITERIA

Articles included were empirical quantitative studies, which examined risks associated with self-harm, suicidal ideation or suicidal behaviour in LGBTQ+ young people (12-25 years).

SYNTHESIS METHODS

2457 articles were identified for screening which was completed by two independent reviewers. 104 studies met inclusion criteria of which 40 had data which could be meta-analysed in a meaningful way. This analysis represents victimisation and mental health difficulties as risks among LGBTQ+ youth with self-harm and suicide experiences. Random-effects modelling was used for the main analyses with planned subgroup analyses.

RESULTS

Victimisation and mental health were key risk factors across the dimension self-harm and suicide identified through all analyses. A pooled prevalence of 0.36 was indicated for victimisation and 0.39 for mental health difficulties within LGBTQ+ young people with experiences of self-harm or suicide. Odds ratios were calculated which demonstrated particularly high levels of victimisation (3.74) and mental health difficulties (2.67) when compared to cisgender, heterosexual counterparts who also had these experiences.

CONCLUSIONS

Victimisation and mental health difficulties are highly prevalent among LGBTQ+ youth with experiences of self-harm and suicide. Due to inconsistency of reporting, further risk synthesis is limited. Given the global inclusion of studies, these results can be considered across countries and inform policy and suicide prevention initiatives.

PROSPERO REGISTRATION NUMBER

CRD42019130037.

The quality and satisfaction of romantic relationships in transgender people: A systematic review of the literature

INTRODUCTION

Romantic relationships are often a significant area of individuals' lives and can have a positive impact on wellbeing. There is often a belief within society of romantic relationships ending upon the start of gender affirming transition, however this is often not reflected within clinical work or research studies. Despite this, currently not enough is known about romantic relationships for transgender individuals and their partners, and the impact gender affirming transition can have on the quality and satisfaction of these relationships.

AIM

To critically and systematically review the available literature examining quality and satisfaction of romantic relationships for transgender individuals and their partners.

METHODS

Using PRISMA guidelines, major databases (Pubmed, PsycINFO and Web of Science) and relevant reference lists were searched for suitable articles up to January 2020. Each included article was assessed for methodological quality and the demographic data, methods and findings linked to relationship quality and satisfaction was extracted for analysis.

RESULTS

From 151 potentially relevant articles, 14 studies (six quantitative, eight qualitative) were included within the review. Most studies displayed moderate risk of bias due to cross-sectional designs and lack of reflexivity. Findings from quantitative studies suggest a bi-directional relationship between transition, relationship quality and satisfaction and wellbeing. Qualitative studies suggest transition can cause personal challenges for both transgender individuals and partners. Maintenance activities help buffer the impact of these challenges on relationship satisfaction and ensure positives are possible from relationships.

DISCUSSION

Gender affirming transition can impact on the quality and satisfaction of romantic relationships. Due to additional challenges transgender individuals and their partners may face, adequate support is required at personal, community and clinical level. There is a paucity of research in this area and current studies lack methodological rigor. Future research is essential to gain a further understanding of transgender relationships and the support required.

European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction"

BACKGROUND

There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice.

AIM

We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction.

METHODS

The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available.

OUTCOMES

The foci of the study are assessment and hormonal aspects of trans health care.

RESULTS

As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment.

CLINICAL IMPLICATIONS

This is an up-to-date ESSM position statement.

STRENGTHS & LIMITATIONS

These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited.

CONCLUSION

This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020;17:570-584.

The stability of autistic traits in transgender adults following cross-sex hormone treatment

Background: Recent research has shown that a high percentage of treatment-seeking transgender adults who were assigned female at birth (AFAB) reported scores above the clinical cutoff for autistic traits. It is unclear whether those scores reflect a stable trait or may be inflated by the high levels of anxiety typically associated with transgender people attending clinical services. Aims: This longitudinal study aims to explore the impact of Cross-sex Hormone Treatment (CHT) on levels autistic traits, independent of changes in anxiety. Method: Transgender adults who were assessed at a national transgender health service in the UK, who had not previously received CHT and who had completed the AQ-Short as a measure of autistic traits pre- and one-year post-CHT were included in the study (n = 118). Anxiety was assessed at the same time points using the Hospital Anxiety and Depression Scale. Results: AQ-Short scores remained very stable over time (ICC = 0.7; CIs 0.591-0.779) but anxiety showed little consistency (ICC = 0.386; CIs 0.219 to 0.531). Repeated measures ANOVA found a main effect of assigned sex with AFAB having higher AQ-Short scores. There was no change in AQ-Short scores and no significant interaction between assigned sex and change in AQ-Short scores. Conclusion: This study confirmed that treatment seeking transgender AFAB people have higher levels of autistic traits at follow-up compared to AMAB transgender people and that these traits are stable following one year of CHT regardless of assigned sex. This may have clinical implications regarding the support that transgender people may require following medical transition.

Examining risk factors for self-harm and suicide in LGBTQ+ young people: a systematic review protocol

INTRODUCTION

Young people who identify as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (LGBTQ+) are at increased risk for self-harm, suicide ideation and behaviours. However, there has yet to be a comprehensive understanding of what risk factors influence these behaviours within LGBTQ+ young people as a whole. The purpose of this systematic review is to examine risk factors associated with self-harm, suicidal ideation and behaviour in LGBTQ+) young people.

METHODS AND ANALYSIS

A systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (MEDLINE, Scopus, EMBASE, PsycINFO and Web of Science) will be systematically searched for cross-sectional, prospective, longitudinal, cohort and case-control designs which examine risk factors for self-harm and/or suicidal ideation and behaviour in LGBTQ+ young people (aged 12-25 years). Only studies published in English will be included. No date restrictions will be applied. Study quality assessment will be conducted using the original and modified Newcastle-Ottawa Scales. Meta-analysis or narrative synthesis will be used, dependent on findings.

ETHICS AND DISSEMINATION

This is a systematic review of published literature and thereby ethical approval was not sought. The review will be submitted to a peer-reviewed journal, be publicly disseminated at conferences focusing on mental health, self-harm and suicide prevention. The findings will also be shared through public engagement and involvement, particularly those related to young LGBTQ+ individuals.

PROSPERO REGISTRATION NUMBER

CRD42019130037.

The terminology of identities between, outside and beyond the gender binary - A systematic review

Background: Recently, a multitude of terms have emerged, especially within North America and Western Europe, which describe identities that are not experienced within the culturally accepted binary structure of gender which prevails within those cultures. As yet, there is no clear single umbrella term to describe such identities and a mixture of words have been used in scholarly work to date. Aims: To explore the origins and track the emergence of newer terms and definitions for identities between, outside and beyond the gender binary, to outline current trends in descriptors within scholarly work and to suggest a term which is wide enough to encompass all identities. Methods: A comprehensive systematic review was made, following the PRISMA guidelines. Several relevant key terms were used to search Web of Science, ScienceDirect, PubMed, and the International Journal of Transgenderism. The descriptions each title gives for identities outside of the binary are extracted for analysis. Results: Several terms have been used over the years to describe identities outside of the binary. "Non-binary" and "genderqueer" are currently mostly used as umbrella terms. However, "gender diverse" is emerging as a more suitable wide-ranging inclusive term for non-male and non-female identities. Discussion: Identity outside of "male" and "female" is an emerging concept which currently has several identifiers and little academic agreement on which is the most pertinent. The two leading descriptors are "non-binary" and "genderqueer." Gender diverse is emerging as a new term which has the aim of including all other terms outside of male and female within it and this article suggests the increase in its use to describe gender identities outside of the binary.

Mental health and quality of life in non-binary transgender adults: a case control study

Background: The social challenges that non-binary people experience, due in part to social intolerance and the lack of validation of non-binary gender identities, may affect the mental health and quality of life of this population. However, studies that have distinguished between non-binary and binary transgender identities are lacking. Aim: To compare the mental health and quality of life of a community sample of non-binary transgender adults with controls (binary transgender people and cisgender people) matched on sex assigned at birth. Method: A total of 526 participants were included. Ninety-seven were classified as non-binary and were compared with two control groups: 91 people classified as binary and 338 cisgender people. Only transgender people not on gender affirming hormone treatment or who had not undergone gender affirming surgery were included. Participants were invited to complete an online survey that included mental health and quality of life measures. Results: Non-binary people reported significantly better mental health than binary transgender people, but worse than cisgender people. Overall, there were no significant differences in quality of life between non-binary and binary transgender participants assigned male at birth and transgender females, but non-binary assigned males at birth had better scores on the psychological and social domains of quality of life than transgender males. Quality of life was better across all domains in cisgender people than transgender groups. Conclusion: There is an inequality with regard to mental health and quality of life between non-binary (and binary) transgender people and the cisgender population that needs to be addressed. The better mental health scores in non-binary people may reflect lower levels of body dissatisfaction among the non-binary population. Mental health problems and poor quality of life are likely to have social causes and hence legislative measures and broader government-led inclusive directives should be put in place to recognize and to validate non-binary identifying people.

SAT-014 No Correlation between Serum Testosterone Levels and Aggression or Anger Intensity in Transgender People: Results from Five European Centres

AIM: Anger is a state of emotions ranging from irritation to intense rage. Aggression is the externalization of anger through destructive/punitive behaviour. The World Professional Association for Transgender Health (WPATH) Standards of Care, Edition 7 (SOC7) guidelines warn about aggression in transgender men (TM) on testosterone treatment. We aimed to assess whether aggression and anger intensity increase in TM and decrease in transgender women (TW) after initiation of gender affirming hormone therapy and to identify predictors for anger intensity in transgender people, including levels of sex steroids as well as psychological measurements. METHODS: Prospective changes in aggression were measured at baseline and after one year of gender affirming hormones in 155 transgender persons (64 TM, 91 TW), using the Inventory of Interpersonal Problems (IIP-32) factor ‘too aggressive’. State-level anger intensity was prospectively assessed in 898 participants (440 TM, 468 TW) by the STAXI-2 (State-Trait Anger Expression Inventory-2) State Anger (S-Anger) questionnaire during a three-year follow-up period, starting at the initiation of hormone treatment (testosterone in TM, oestrogens plus anti-androgens in TW). At baseline, psychological questionnaires were administered. Data were analysed cross-sectionally and prospectively. RESULTS: No prospective changes were reported in ‘too aggressive’ scores (after one year of hormone therapy) and S-Anger scores (over 3, 12 and 36 months of hormone therapy) in TM and TW. ‘Too aggressive’ scores were positively correlated to increasing anxiety scores in the entire study population and with lower support from friends in TW. At three, twelve and thirty-six months of gender affirming hormone therapy, anger intensity was not correlated to serum testosterone levels, although there was a correlation with various psychological measures after three and twelve months. TM experiencing menstrual spotting after three months had higher S-Anger scores compared to those without (median 26.5 [18.0 - 29.8] versus 15.0 [15.0 - 17.0], P=0.020). Changes in STAXI-2 S-Anger scores were not correlated to changes in serum testosterone levels after three, twelve and thirty-six months in TM or TW. CONCLUSIONS: Aggression and state-level anger intensity are associated with psychological and/or psychiatric vulnerability or the persistence of menses in TM, but not with exogenous testosterone therapy in TM or serum testosterone levels in both TM and TW.

Gender congruence and body satisfaction in nonbinary transgender people: A case control study

Background: Binary transgender people access gender affirming medical interventions to alleviate gender incongruence and increase body satisfaction. Despite the increase in nonbinary transgender people, this population are less likely to access transgender health services compared to binary transgender people. No research has yet understood why by exploring levels of gender congruence and body satisfaction in nonbinary transgender people. Objective: The aim of this study was to compare levels of gender congruence and body satisfaction in nonbinary transgender people to controls [binary transgender people and cisgender (nontrans) people]. Method: In total, 526 people from a community sample in the UK took part in the study (97 nonbinary, 91 binary, and 338 cisgender identifying people). Participants were asked to complete an online survey about gender congruence and body satisfaction. Results: There were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender and body satisfaction compared to binary transgender people. However, there was no difference in congruence and satisfaction with social gender role between the two transgender groups (nonbinary and binary). Cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary). Conclusions: There are differences in gender congruence and body satisfaction between nonbinary and binary transgender people. Nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people. Transgender health services need to be more inclusive of nonbinary transgender people and their support and treatment needs, which may differ from those who identify within the binary gender system.

Endocrinology of Transgender Medicine

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.

Autistic Traits in Treatment-Seeking Transgender Adults

The present study aimed to compare prevalence of autistic traits measured by the self-reported autism spectrum quotient-short (AQ-short) in a transgender clinical population (n = 656) matched by age and sex assigned at birth to a cisgender community sample. Results showed that transgender and cisgender people reported similar levels of possible autistic caseness. Transgender people assigned female were more likely to have clinically significant autistic traits compared to any other group. No difference was found between those assigned male. High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people’s high social anxiety levels due to negative past experiences.

Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis

The study aims to systematically extract and analyse data about Quality of Life (QoL) in the transgender population. A systematic literature search and meta-analysis were conducted using the MEDLINE, EMBASE, PubMed, and PsycINFO databases, up to July 2017. Only English language quantitative studies, in adults, which reported the means for validated QoL measures were included. Random-effect meta-analysis was adopted to pool data and estimate the 95% Confidence Intervals (CI). From 94 potentially relevant articles, 29 studies were included within the review and data extraction for meta-analysis was available in 14 studies. The majority of the studies were cross-sectional, lacked controls and displayed moderate risk of bias. Findings from the systematic review suggested that transgender people display poor QoL, independent of the domain investigated. Pooling across studies showed that transgender people report poorer mental health QoL compared to the general population (-0.78, 95% CI = -1.08 to -0.48, 14 studies). However, meta-analysis in a subgroup of studies looking at QoL in participants who were exclusively post-CHT found no difference in mental health QoL between groups (-0.42, 95% CI = -1.15 to 0.31; 7 studies). There was insufficient data for a pre-treatment subgroup. Evidence suggests that transgender people have lower QoL than the general population. Some evidence suggests that QoL improves post-treatment. Better quality studies that include clearly defined transgender populations, divided by stage of gender affirming treatment and with appropriate matched control groups are needed to draw firmer conclusions.

A randomized controlled trial of the compuLsive Exercise Activity TheraPy (LEAP): A new approach to compulsive exercise in anorexia nervosa

OBJECTIVE

To compare the efficacy of the compuLsive Exercise Activity theraPy (LEAP) programme integrated with manualized cognitive behavioral therapy for anorexia nervosa (CBT-AN) compared to CBT-AN alone.

METHOD

Seventy-eight adults were randomized to CBT-AN, delivered with or without eight embedded sessions of LEAP, for a total of 34 individual outpatient sessions. Participants were assessed at baseline, the end of the first phase of CBT-AN (which included LEAP), mid-therapy, end of therapy, and at 3 and 6 months follow-up. Linear mixed effects modelling was used for comparing trajectories over time by group in primary outcomes of pathological exercise cognitions and secondary outcomes of exercise frequency, BMI, eating disorder (ED) symptoms, AN stage of change, anxiety/depression, and health related quality of life.

RESULTS

There were significant improvements over time in all outcomes. There were no significant differences between treatment groups in primary outcome measures. Fidelity and end-of-treatment participant satisfaction were satisfactory across both conditions.

DISCUSSION

CBT-AN and LEAP added to CBT-AN resulted in improved attitudes and beliefs toward exercise and general improvements in BMI and ED psychopathology in people with AN.

Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services

BACKGROUND

Depression is a serious disorder which significantly impacts wellbeing and quality of life. Studies exploring mental wellbeing in the transgender population are mostly limited by small, non-homogenous samples and lack of matched controls. This study aimed to address these limitations and explore depression rates in a large sample of transgender people, compared with matched controls from the general population, as well as factors predicting depression in those taking cross-sex hormone treatment (CHT) compared to those not.

METHODS

Transgender individuals (n = 913) completed a measure of depression, measures which predict psychopathology (self-esteem, victimization, social support, interpersonal problems), and information regarding CHT use. Participants were matched by age and experienced gender with adults from the general population who had completed the measure of depression.

RESULTS

Individuals were categorized as having no, possible or probable depressive disorder. Transgender individuals not on CHT had a nearly four-fold increased risk of probable depressive disorder, compared to controls. Older age, lower self-esteem, poorer interpersonal function and less social support predicted depressive disorder. Use of CHT was associated with less depression.

LIMITATIONS

Participants were attending a national gender identity service and therefore represent only a sub-group of transgender people. Due to the cross-sectional design, longitudinal research is required to fully confirm the finding that CHT use reduces depression.

CONCLUSION

This study confirms that non-treated transgender individuals have an increased risk of a depressive disorder. Interventions offered alongside gender affirming treatment to develop interpersonal skills, increase self-esteem and improve social support may reduce depression and prepare individuals for a more successful transition.

Sport and Transgender People: A Systematic Review of the Literature Relating to Sport Participation and Competitive Sport Policies

Background

Whether transgender people should be able to compete in sport in accordance with their gender identity is a widely contested question within the literature and among sport organisations, fellow competitors and spectators. Owing to concerns surrounding transgender people (especially transgender female individuals) having an athletic advantage, several sport organisations place restrictions on transgender competitors (e.g. must have undergone gender-confirming surgery). In addition, some transgender people who engage in sport, both competitively and for leisure, report discrimination and victimisation.

Objective

To the authors’ knowledge, there has been no systematic review of the literature pertaining to sport participation or competitive sport policies in transgender people. Therefore, this review aimed to address this gap in the literature.

Method

Eight research articles and 31 sport policies were reviewed.

Results

In relation to sport-related physical activity, this review found the lack of inclusive and comfortable environments to be the primary barrier to participation for transgender people. This review also found transgender people had a mostly negative experience in competitive sports because of the restrictions the sport’s policy placed on them. The majority of transgender competitive sport policies that were reviewed were not evidence based.

Conclusion

Currently, there is no direct or consistent research suggesting transgender female individuals (or male individuals) have an athletic advantage at any stage of their transition (e.g. cross-sex hormones, gender-confirming surgery) and, therefore, competitive sport policies that place restrictions on transgender people need to be considered and potentially revised.

A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary

Background : Previous research has consistently reported high rates of mental health symptomatology and lower social support in young treatment seeking transgender individuals. However, these studies have failed to distinguish between transgender people who identify within the gender binary and those who identify as non-binary. Aims : This study aimed to compare levels of mental health symptomatology (anxiety, depression, and non-suicidal self-injury behavior) and social support of treatment seeking non-binary transgender young individuals with those self-identified as binary transgender young individuals. All participants attended a national transgender health service in the UK during a 2-year period. Measures : Age and gender identity descriptors were collected, as well as clinical measures of anxiety and depression (Hospital Anxiety and Depression Scale), self-esteem (The Rosenberg Self-Esteem Scale), non-suicidal self-injury (Non-Suicidal Self-Injury: Treatment Related), and social support (Multidimensional Scale of Perceived Social Support). Results : A total of 388 young people, aged 16-25 years, agreed participation; 331 (85.3%) identified as binary and 57 (14.7%) as non-binary. Analysis of the data showed the non-binary group experienced significantly more anxiety and depression and had significantly lower self-esteem than the binary group. There were no significant differences between groups in the likelihood of engaging in non-suicidal self-injury behavior or levels of social support. Conclusions : Non-binary identifying treatment seeking transgender youth are at increased risk of developing anxiety, depression, and low self-esteem compared to binary transgender youth. This may reflect the even greater barriers and feelings of discrimination that may be faced by those whose identity does not fit the notion of binary gender that is pervasive in how society views both cis- and transgender populations.

The Gender Congruence and Life Satisfaction Scale (GCLS): Development and validation of a scale to measure outcomes from transgender health services

Background: It is vital that the treatment offered at transgender health services can be evaluated to ensure a high quality of care. However, the tools currently used to evaluate treatment at transgender health services are limited by mainly focusing on mental health or because they have been developed for binary transgender people only. This study therefore aimed to develop and validate a tool that addresses these limitations. The Gender Congruence and Life Satisfaction Scale (GCLS) was developed through reviewing the literature, conducting interviews with transgender people, and holding discussions with experts working in transgender healthcare. An initial pool of items was developed and feedback on these was obtained. The tool was then validated. Method: For the validation of the tool, a total of 789 participants (451 transgender [171 transgender females, 147 transgender males, 133 people identifying as non-binary], and 338 cisgender [254 females, 84 males]) were recruited from the United Kingdom to test the factor structure and validity of the GCLS. Results: Exploratory factor analysis retained 38 items which formed seven subscales (psychological functioning; genitalia; social gender role recognition; physical and emotional intimacy; chest; other secondary sex characteristics; and life satisfaction). These seven subscales were found to have good internal consistency and convergent validity. The GCLS was also found to be capable of discriminating between groups (e.g., people who have and have not undergone gender affirming medical interventions). Transgender and cisgender subscale norms are provided for the GCLS. Conclusion: The GCLS is a suitable tool to use with the transgender population to measure health-related outcomes for both clinical and research purposes.

Relationships between compulsive exercise, quality of life, psychological distress and motivation to change in adults with anorexia nervosa

BACKGROUND

For people with anorexia nervosa (AN), compulsive exercise is characterized by extreme concerns about the perceived negative consequences of stopping/reducing exercise, dysregulation of affect, and inflexible exercise routines. It is associated with increased eating disorder psychopathology and poor clinical outcome. However, its relationships with two important clinical issues, quality of life (QoL) and motivation to change, are currently unknown. This study aimed to assess the cross-sectional relationships between compulsive exercise, QoL, psychological distress (anxiety and depressive symptoms, and obsessive-compulsive traits) and motivation to change in patients with AN.

METHOD

A total of 78 adults with AN participated in this study, which was nested within a randomized controlled trial of psychological treatments for AN. At baseline (pre-treatment), participants completed questionnaires assessing compulsive exercise, eating disorder (ED) psychopathology, QoL, psychological distress and motivation to change.

RESULTS

Baseline correlational analyses demonstrated a moderate positive relationship between compulsive exercise and ED psychopathology, and a weak positive relationship between compulsive exercise and psychological distress. There was a moderate negative relationship between compulsive exercise and eating disorder QoL.

CONCLUSIONS

These results indicate compulsive exercise is moderately associated with poorer QoL and weakly associated with higher distress. Targeting compulsive exercise in the treatment of anorexia nervosa may help reduce the burden of illness and improve patients' engagement in treatment.

TRIAL REGISTRATION

ACTRN12610000585022. Taking a LEAP forward in the treatment of anorexia nervosa: a randomized controlled trial. NHMRC grant: 634922.

Detecting Eating Psychopathology in Female Athletes by Asking About Exercise: Use of the Compulsive Exercise Test

The present study assessed the suitability of the Compulsive Exercise Test (athlete version; CET-A) for identifying female athletes with clinically significant features related to or comparable with eating psychopathology. Three hundred and sixty-one female athletes (including 12 with a clinically diagnosed eating disorder) completed the Eating Disorders Examination Questionnaire and the CET-A. Receiver operating curve analysis was employed to identify a cut-off value on the CET-A, which could indicate clinically significant features related to or comparable with eating psychopathology among female athletes. The analysis demonstrated that a CET-A score of 10 successfully discriminated female athletes with a current eating disorder. The results suggest that the CET-A may be a suitable tool for detecting eating psychopathology in female athletes. Additional longitudinal research is needed to evaluate the predictive value of the CET-A. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Perceived role of psychiatrists in the management of substance misuse a questionnaire survey

Aims and methods

A postal questionnaire sent to all psychiatrists working in four NHS trusts in and around Birmingham was used to survey the number of new cases of drug and alcohol misuse identified in the previous month and the degree of postgraduate training in the management of such cases. Attitudes and beliefs about substance misuse problems were also elicited.

Results

A response rate of 70% was achieved across six sub-specialities in psychiatry and four levels of training. Of the 143 respondents, over half had identified at least one new case of alcohol (61%) or drug misuse (55%) in the previous month. Approximately half of the sample admitted to having received no training in management of substance misuse cases in the previous five years (45% alcohol 50% drugs). There was general agreement about the potential management role of the doctor in the field, but less consensus on whether the clinician had a responsibility to intervene in such cases. A clear discrepancy was demonstrated between psychiatrists' perceptions of the evidence supporting various treatments and the actual evidence base.

Clinical implications

The study highlights the pressing need for training psychiatrists at all levels and in all sub-specialities in the management of substance misuse.

Managing physical risk in anorexia nervosa

Eating disorders encompass physical, psychological and social pathologies that increase health risk. Anorexia nervosa has the highest mortality of any psychiatric disorder, but patients are not always managed by specialist eating disorders services and the duty of care sometimes falls to the general psychiatrist. This article is an aide-memoire for assessing and managing physical risk in patients with anorexia nervosa.

Adolescent units: a need for change?

Aims and Method

To describe the characteristics and diagnoses of patients admitted to a general adolescent psychiatric in-patient unit. We describe the age, gender and psychiatric diagnosis of the patient, as well as whether the patient exhibited violent behaviour in the ward, whether he/she needed to be transferred to a different service and whether he/she was admitted under a section of the Mental Health Act 1983.

Results

Patients were evenly distributed in terms of gender, with most being 14–16 years old. Diagnoses were varied with adjustment disorder predominating, but could be separated into four main groups. Levels of violence were high, being associated with detention under the Mental Health Act 1983, and often resulted in transfer to another service.

Clinical Implications

The needs of certain adolescents admitted to a general-purpose adolescent unit may not be best met in this environment. Current services must change to meet the needs of their patients. There may be a need for greater specialisation.

Psychometric Properties of the Chinese Version of the Eating Attitudes Test in Young Female Patients with Eating Disorders in Mainland China

The study aimed to investigate the reliability and validity of the Chinese version of the eating attitudes test (EAT-26) among female adolescents and young adults in Mainland China. This scale was administered to 396 female eating disorder patients and 406 noneating disorder healthy controls, in addition 35 healthy controls completed a retest after a 4-week intervals. Tests for reliability, convergent validity and receiver operating characteristic analysis were performed to detect the psychometric properties. The EAT-26 demonstrated good internal consistency (Cronbach's alpha = 0.822-0.922), test-retest reliability (interclass correlation coefficient = 0.817) and convergent validity(r = 0.450-0.750). The receiver operating characteristic analysis showed that the cut-off 14 for anorexia nervosa and 15 for bulimia nervosa represented good compromises with approximate sensitivity (0.66-0.68) and specificity (0.85-0.86). Our findings provided evidence that the Chinese version of the EAT-26 was a psychometrically reliable and valid self-rating instrument for identifying people suffering from an eating disorder in Mainland China. A clinical cut-off range between 14 and 15 could be used, but caution should be exercised because of the low sensitivity of the tool. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Transition Care in Anorexia Nervosa Through Guidance Online from Peer and Carer Expertise (TRIANGLE): Study Protocol for a Randomised Controlled Trial

TRIANGLE is a multicentre trial investigating whether the addition of a novel intervention for patients and carers (ECHOMANTRA) to treatment as usual (TAU) improves outcomes for people with anorexia nervosa (AN). ECHOMANTRA is based on the cognitive interpersonal model of AN and includes assessments, workbooks, videos, online groups and joint Skype sessions for patients and carers. People receiving intensive hospital treatment (N = 380) will be randomised to TAU or TAU plus ECHOMANTRA. Participants will be assessed over an 18-month period following randomisation. The primary outcome is patient psychological well-being at 12 months postrandomisation. Secondary outcomes include (i) patient's weight, eating disorder symptoms, motivation to change, quality of life and number of days in hospital at 12 months postrandomisation and (ii) carer's psychological well-being, burden and skills at 12 months (some outcomes will be assessed at 18 months postrandomisation). The results from this trial will establish the effectiveness of ECHOMANTRA.

TRIAL REGISTRATION

ISRCTN registry ISRCTN14644379, 08/12/2016. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.