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Chiang T, Bachmann GA. TranZap: A Transgender Resource for Identifying Gender-Affirming Providers. Sex Med Rev 2022:S2050-0521(22)00047-6. [PMID: 36030176 DOI: 10.1016/j.sxmr.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Many transgender individuals seeking healthcare have had at least one negative experience related to being transgender. As a result, transgender patients may forego seeking healthcare treatment atall, leading to adverse long-term health outcomes. With barriers to care and oftentimes suboptimal care provided to transgender individuals, TranZap, in collaboration with the PROUD Gender Center of NJ, was commenced. OBJECTIVES To provide a review on the current transgender resources to finding healthcare, and the impetus behind creating a transgender health app to streamline this process. The vision of this app, TranZap, is to empower transgender individuals who are seeking healthcare such that they are better educated and knowledgeable regarding available healthcare providers. METHODS With no data available from usual sources, such as Google Scholar, social media, as well as input from the transgender community through social media and word of mouth was utilized to identify the current resources for transgender patients seeking healthcare. This online search was done to identify any type of transgender focused healthcare databases that were community driven. RESULTS Four resources were identified: TransBucket, TransAtlas, TransHealthCare, and Erin's Informed Consent hormone replacement therapy map of the US. Noting that there are limited resources, an app that is community driven and provides information on all types of healthcare providers, not exclusively surgeons or endocrinologists, was developed. CONCLUSION Seeking gender-affirming healthcare providers is a strenuous task filled with uncertainty and few reliable resources. Resources that provide the input of transgender individuals on their experiences with healthcare providers is one step in addressing this issue. Resources, such as TranZap, must be developed to close the gaps in access to healthcare by providing a platform for transgender patients to share experiences about healthcare providers in the hopes that those using the app will be able to find a welcoming gender-affirming provider. Chiang T, Bachmann GA. The TranZap: A Transgender Resource for Identifying Gender-Affirming Providers. Sex Med Rev 2022;XX:XXX-XXX.
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Compte EJ, Cattle CJ, Lavender JM, Brown TA, Murray SB, Capriotti MR, Flentje A, Lubensky ME, Obedin-Maliver J, Lunn MR, Nagata JM. Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people. J Eat Disord 2022; 10:95. [PMID: 35794647 PMCID: PMC9260975 DOI: 10.1186/s40337-022-00618-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Muscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study. METHODS We evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18-74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study. RESULTS Using a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating. CONCLUSIONS These findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.
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Affiliation(s)
- Emilio J Compte
- Eating Behavior Research Center, School of Psychology, Universidad Adolfo Ibáñez, Santiago, Chile
- Research Department, Comenzar de Nuevo Treatment Center, Monterrey, Mexico
| | - Chloe J Cattle
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA
| | - Jason M Lavender
- Military Cardiovascular Outcomes Research Program (MiCOR), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Metis Foundation, San Antonio, TX, USA
| | - Tiffany A Brown
- Department of Psychological Sciences, Auburn University, Auburn, AL, USA
| | - Stuart B Murray
- Department of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Matthew R Capriotti
- Department of Psychology, San José State University, San Jose, CA, USA
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
| | - Annesa Flentje
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Community Health Systems, University of California, San Francisco, San Francisco, CA, USA
- Alliance Health Project, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Micah E Lubensky
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Community Health Systems, University of California, San Francisco, San Francisco, CA, USA
| | - Juno Obedin-Maliver
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Mitchell R Lunn
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jason M Nagata
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA.
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Kennis M, Duecker F, T’Sjoen G, Sack AT, Dewitte M. Mental and sexual well-being in non-binary and genderqueer individuals. Int J Transgend Health 2021; 23:442-457. [PMID: 36324878 PMCID: PMC9621256 DOI: 10.1080/26895269.2021.1995801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Non-binary and genderqueer (NBGQ) individuals do not identify with a binary gender identity. Some but not all NBGQ individuals identify as transgender, and it is currently unclear on which aspects of mental and sexual well-being NBGQ and binary transgender individuals may differ. AIM To compare NBGQ, binary transgender and cisgender individuals on variables related to mental well-being, sexual well-being, and sexual self-concept discrepancies. METHODS We conducted an online questionnaire study in 125 transgender men, 72 transgender women, 78 NBGQ individuals, 98 cisgender men, and 107 cisgender women. RESULTS For most variables, NBGQ individuals did not differ from binary transgender individuals. These two groups differed only on gender dysphoria and transgender specific body image worries, which were both lower in the NBGQ group. Compared to the cisgender group, NBGQ individuals scored higher on gender dysphoria, actual/ought sexual self-concept discrepancies, and actual/ideal sexual self-concept discrepancies, and lower on general life satisfaction and sexual esteem related to body perception. DISCUSSION These results offer a first quantitative analysis of sexual well-being in NBGQ individuals, and highlight that - while both groups face unique challenges - NBGQ individuals encounter similar difficulties concerning mental and sexual well-being as binary transgender individuals.
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Affiliation(s)
- Mathilde Kennis
- Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht, Netherlands
| | - Felix Duecker
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht, Netherlands
| | - Guy T’Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Alexander T. Sack
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht, Netherlands
- Department of Psychiatry and Neuropsychology, Maastricht, Netherlands
- Center for Integrative Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Marieke Dewitte
- Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
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Nagata JM, Compte EJ, McGuire FH, Lavender JM, Brown TA, Murray SB, Flentje A, Capriotti MR, Lubensky ME, Obedin-Maliver J, Lunn MR. Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among gender minority populations. J Eat Disord 2021; 9:87. [PMID: 34261536 PMCID: PMC8278632 DOI: 10.1186/s40337-021-00442-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/02/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Representing the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of heightened body image-related concerns among gender minority populations, little is known about the degree of MD symptoms among gender minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to assess community norms of the MDDI in gender-expansive people, transgender men, and transgender women. METHOD Data from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people, were examined. We calculated means, standard deviations, and percentiles for the MDDI total and subscale scores among gender-expansive people (i.e., those who identify outside of the binary system of man or woman; n = 1023), transgender men (n = 326), and transgender women (n = 177). The Kruskal-Wallis test was used to assess group differences and post hoc Dunn's tests were used to examine pairwise differences. RESULTS Transgender men reported the highest mean MDDI total score (30.5 ± 7.5), followed by gender-expansive people (27.2 ± 6.7), then transgender women (24.6 ± 5.7). The differences in total MDDI score were driven largely by the Drive for Size subscale and, to a lesser extent, the Functional Impairment subscale. There were no significant differences in the Appearance Intolerance subscale among the three groups. CONCLUSIONS Transgender men reported higher Drive for Size, Functional Impairment, and Total MDDI scores compared to gender-expansive people and transgender women. These norms provide insights into the experience of MD symptoms among gender minorities and can aid researchers and clinicians in the interpretation of MDDI scores among gender minority populations.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, University of California, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA, 94158, USA.
| | - Emilio J Compte
- Eating Behavior Research Center, School of Psychology, Universidad Adolfo Ibáñez, Santiago, Chile
- Research Department, Comenzar de Nuevo Treatment Center, Monterrey, Mexico
| | - F Hunter McGuire
- The Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Jason M Lavender
- Military Cardiovascular Outcomes Research Program (MiCOR), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Metis Foundation, San Antonio, TX, USA
| | - Tiffany A Brown
- Department of Psychiatry, University of California, San Diego, CA, USA
- San Diego State University Research Foundation, San Diego, CA, USA
| | - Stuart B Murray
- Department of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, CA, USA
| | - Annesa Flentje
- Department of Community Health Systems, University of California, San Francisco, San Francisco, CA, USA
- Alliance Health Project, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
| | - Matthew R Capriotti
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Psychology, San José State University, San Jose, CA, USA
| | - Micah E Lubensky
- Department of Community Health Systems, University of California, San Francisco, San Francisco, CA, USA
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
| | - Juno Obedin-Maliver
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Mitchell R Lunn
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Nagata JM, Compte EJ, Cattle CJ, Flentje A, Capriotti MR, Lubensky ME, Murray SB, Obedin-Maliver J, Lunn MR. Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among gender-expansive populations. J Eat Disord 2020; 8:74. [PMID: 33292636 DOI: 10.1186/s40337-020-00352-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Gender-expansive individuals (i.e., those who identify outside of the binary system of man or woman) are a marginalized group that faces discrimination and have a high burden of mental health problems, but there is a paucity of research on eating disorders in this population. This study aimed to describe the community norms for the Eating Disorder Examination Questionnaire (EDE-Q) in gender-expansive populations. METHODS The participants were 988 gender-expansive individuals (defined as neither exclusively cisgender nor binary transgender) from The PRIDE study, an existing longitudinal cohort study of health outcomes in sexual and gender minority people. RESULTS We present the mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in this group as a whole and stratified by sex assigned at birth. Gender-expansive individuals reported any occurrence (≥1/28 days) of dietary restraint (23.0%), objective binge episodes (12.9%), excessive exercise (7.4%), self-induced vomiting (1.4%), or laxative misuse (1.2%). We found no statistically significant differences by sex assigned at birth. Compared to a prior study of transgender men and women, there were no significant differences in eating attitudes or disordered eating behaviors noted between gender-expansive individuals and transgender men. Transgender women reported higher Restraint and Shape Concern subscale scores compared to gender-expansive individuals. Compared to a prior study of presumed cisgender men 18-26 years, our age-matched gender-expansive sample had higher Eating, Weight, and Shape Concern subscales and Global Score, but reported a lower frequency of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-25 years, our age-matched gender-expansive sample had a higher Shape Concern subscale score, a lower Restraint subscale score, and lower frequencies of self-induced vomiting, laxative misuse, and excessive exercise. CONCLUSIONS Gender-expansive individuals reported lower Restraint and Shape Concern scores than transgender women; higher Eating, Weight, and Shape Concern scores than presumed cisgender men; and lower Restraint but higher Shape Concern scores than presumed cisgender women. These norms can help clinicians in treating this population and interpreting the EDE-Q scores of their gender-expansive patients.
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Rider GN, Vencill JA, Berg DR, Becker-Warner R, Candelario-Pérez L, Spencer KG. The gender affirmative lifespan approach (GALA): A framework for competent clinical care with nonbinary clients. INT J TRANSGENDERISM 2019; 20:275-288. [PMID: 32999613 PMCID: PMC6831004 DOI: 10.1080/15532739.2018.1485069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The limited research on nonbinary individuals suggests that this community experiences significant health disparities. Compared to binary transgender individuals, research suggests that nonbinary individuals are at elevated risk for discrimination and negative mental health outcomes, including depression, anxiety, traumatic stress, and suicidality. Even mental health providers who work with binary transgender individuals often lack knowledge of and training to work competently with nonbinary individuals. Methods: The authors of this conceptual article present the Gender Affirmative Lifespan Approach (GALA), a psychotherapy framework based in health disparities theory and research, which asserts that therapeutic interventions combating internalized oppression have the potential to improve mental health symptomatology resulting in improved overall health and well-being for gender diverse clients. GALA's therapeutic interventions are designed to promote positive gender identity development through five core components: (1) building resiliency; (2) developing gender literacy; (3) moving beyond the binary; 4) promoting positive sexuality; and (5) facilitating empowering connections to medical interventions (if desired). Results: The core components of the GALA model are individualized to each client's unique needs, while taking into consideration age and acknowledging developmental shifts in, or fluidity of, gender across the lifespan. This model represents an inclusive, trans-affirmative approach to competent clinical care with nonbinary individuals. Discussion: Application of the GALA model with nonbinary clients is discussed, including one clinical case vignette.
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Affiliation(s)
- G. Nic Rider
- National Center for Gender Spectrum Health,
Program in Human Sexuality, Department of Family Medicine and Community Health,
University of Minnesota Medical School, Minneapolis, Minnesota,
USA
| | - Jennifer A. Vencill
- Division of General Internal Medicine,
Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN,
USA
| | - Dianne R. Berg
- National Center for Gender Spectrum Health,
Program in Human Sexuality, Department of Family Medicine and Community Health,
University of Minnesota Medical School, Minneapolis, Minnesota,
USA
| | - Rachel Becker-Warner
- National Center for Gender Spectrum Health,
Program in Human Sexuality, Department of Family Medicine and Community Health,
University of Minnesota Medical School, Minneapolis, Minnesota,
USA
| | - Leonardo Candelario-Pérez
- National Center for Gender Spectrum Health,
Program in Human Sexuality, Department of Family Medicine and Community Health,
University of Minnesota Medical School, Minneapolis, Minnesota,
USA
| | - Katherine G. Spencer
- National Center for Gender Spectrum Health,
Program in Human Sexuality, Department of Family Medicine and Community Health,
University of Minnesota Medical School, Minneapolis, Minnesota,
USA
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Koehler A, Eyssel J, Nieder TO. Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals. J Sex Med 2017; 15:102-113. [PMID: 29229223 DOI: 10.1016/j.jsxm.2017.11.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Health care for transgender and transsexual (ie, trans) individuals has long been based on a binary understanding of gender (ie, feminine vs masculine). However, the existence of non-binary or genderqueer (NBGQ) genders is increasingly recognized by academic and/or health care professionals. AIM To gain insight into the individual health care experiences and needs of binary and NBGQ individuals to improve their health care outcomes and experience. METHODS Data were collected using an online survey study on experiences with trans health care. The non-clinical sample consisted of 415 trans individuals. An individual treatment progress score was calculated to report and compare participants' individual progress toward treatment completion and consider the individual treatment needs and definitions of completed treatment (ie, amount and types of different treatments needed to complete one's medical transition). OUTCOMES Main outcome measures were (i) general and trans-related sociodemographic data and (ii) received and planned treatments. RESULTS Participants reported binary (81.7%) and different NBGQ (18.3%) genders. The 2 groups differed significantly in basic demographic data (eg, mean age; P < .05). NBGQ participants reported significantly fewer received treatments compared with binary participants. For planned treatments, binary participants reported more treatments related to primary sex characteristics only. Binary participants required more treatments for a completed treatment than NBGQ participants (6.0 vs 4.0). There were no differences with regard to individual treatment progress score. CLINICAL TRANSLATION Because traditional binary-focused treatment practice could have hindered NBGQ individuals from accessing trans health care or sufficiently articulating their needs, health care professionals are encouraged to provide a holistic and individual treatment approach and acknowledge genders outside the gender binary to address their needs appropriately. STRENGTHS AND LIMITATIONS Because the study was made inclusive for non-patients and individuals who decided against trans health care, bias from a participant-patient double role was prevented, which is the reason the results are likely to have a higher level of validity than a clinical sample. However, because of the anonymity of an online survey, it remains unclear whether NBGQ individuals live according to their gender identity in their everyday life. CONCLUSION The study highlights the broad spectrum of genders in trans-individuals and associated health care needs and provides a novel approach to measure individual treatment progress in trans individuals. Koehler A, Eyssel J, Nieder TO. Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals. J Sex Med 2018;15:102-113.
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Affiliation(s)
- Andreas Koehler
- Interdisciplinary Transgender Health Care Center Hamburg, Department for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Germany
| | - Jana Eyssel
- Interdisciplinary Transgender Health Care Center Hamburg, Department for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Germany
| | - Timo O Nieder
- Interdisciplinary Transgender Health Care Center Hamburg, Department for Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Germany.
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Abstract
Some people have a gender which is neither male nor female and may identify as both male and female at one time, as different genders at different times, as no gender at all, or dispute the very idea of only two genders. The umbrella terms for such genders are 'genderqueer' or 'non-binary' genders. Such gender identities outside of the binary of female and male are increasingly being recognized in legal, medical and psychological systems and diagnostic classifications in line with the emerging presence and advocacy of these groups of people. Population-based studies show a small percentage--but a sizable proportion in terms of raw numbers--of people who identify as non-binary. While such genders have been extant historically and globally, they remain marginalized, and as such--while not being disorders or pathological in themselves--people with such genders remain at risk of victimization and of minority or marginalization stress as a result of discrimination. This paper therefore reviews the limited literature on this field and considers ways in which (mental) health professionals may assist the people with genderqueer and non-binary gender identities and/or expressions they may see in their practice. Treatment options and associated risks are discussed.
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Affiliation(s)
- Christina Richards
- a Nottingham Centre for Gender Dysphoria , Nottingham , UK ;,b Charing Cross Gender Identity Clinic , London , UK
| | | | - Leighton Seal
- b Charing Cross Gender Identity Clinic , London , UK
| | - Meg John Barker
- c Department of Psychology in Social Sciences , Open University , Milton Keynes , UK
| | - Timo O Nieder
- d Interdisciplinary Transgender Health Care Centre Hamburg, Department for Sex Research and Forensic Psychiatry , University Medical Centre Hamburg-Eppendorf (UKE) , Germany
| | - Guy T'Sjoen
- e Centre for Sexology and Gender, Department of Endocrinology , Ghent University , Belgium
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