Beyond the Binary: Gender Inclusivity in Schizophrenia Research

Schizophrenia is a severe neuropsychiatric disorder with significant differences in the incidence and symptomology between cisgender men and women. In recent years, considerably more attention has been on the inclusion of sex and gender in schizophrenia research. However, the majority of this research has failed to consider gender outside of the socially constructed binary of men and women. As a result, little is known about schizophrenia in transgender and gender-nonconforming populations. In this review, we present evidence showing that transgender and gender-nonconforming individuals have elevated risk of developing schizophrenia, and we discuss minority stress theory and other potential factors that may contribute to this risk. The need for inclusion of transgender and gender-nonconforming communities in schizophrenia research is emphasized, alongside a discussion on considerations and challenges associated with this type of research. Finally, we offer specific strategies to make research on schizophrenia, and research on other neuropsychiatric disorders, more inclusive of those populations that do not fall within the socially constructed gender binary. If we are to succeed in the development of more personalized therapeutic approaches for all, a better understanding of the variability of the human brain is needed.

Developing medical professionalism in care of gender nonconforming patients: Reflections of second-year medical students after a curricular experience with gender nonconforming people and allies

INTRODUCTION

Negative healthcare experiences persist for gender nonconforming individuals. Clinician-related factors, including lack of comfort with gender nonconforming persons and unexamined personal biases, present barriers to equitable and affirming healthcare. We explored the effects of contact with gender nonconforming individuals in preclinical medical education through a structured curricular intervention designed to build medical and humanistic knowledge and stimulate the development of medical professionalism surrounding the care of gender nonconforming individuals.

METHODS

A curricular module (didactic prework, time-synchronous online panel discussion, and post-event written reflection) was implemented in a second-year preclinical course in a large multi-campus Midwestern medical school. The module was based on pedagogical foundations of contact theory and reflective writing. Post-event written reflections were investigated using thematic analysis.

RESULTS

Analysis of 355 written reflections revealed three major themes (moments of insight, topics of confusion, connections to professional identity formation) and eight sub-themes. The findings demonstrated emerging gender professionalism and the importance of contact in professional development.

DISCUSSION

Contact with gender nonconforming people and the use of written reflections can encourage self-examination and foster professional identity formation among preclinical medical students. Modeling gender-affirming approaches may help counteract negative cultural messages about gender nonconforming people, aiding development of inclusive future physicians.

Associations between gender identity, eating disorder psychopathology, and food insecurity among Canadian adolescents and young adults during the COVID-19 pandemic

There is a clear association between food insecurity and eating disorder (ED) psychopathology, mainly among samples in the United States and prior to the COVID-19 pandemic. However, Canadians experience food insecurity as well, which may have been heightened by the pandemic and its associated restrictions. The associations between food insecurity and ED psychopathology among Canadians remains underexamined. Therefore, the purpose of this study was to explore associations between food insecurity and ED psychopathology by gender identity among a national sample Canadian adolescents and young adults. Data were collected from 2714 participants aged 16 to 30 years old from across Canada. Participants reported sociodemographic characteristics, ED psychopathology, and food insecurity experienced during the COVID-19 pandemic through an online survey. Descriptive statistics, chi-square tests, ANOVAs, and regression analyses were conducted. Overall, 8.9% of the sample experienced food insecurity, with the highest prevalence among transgender and gender nonconforming individuals. Generally, those with no food insecurity reported the lowest ED psychopathology compared to higher ED psychopathology among those with food insecurity. Several unique differences were observed between cisgender men and cisgender women, while there were no significant associations between food insecurity and ED psychopathology found among transgender and gender nonconforming individuals. Further research is needed to investigate how the relationship between food insecurity and ED psychopathology differs based on gender, and to continue to explore food insecurity experienced beyond the COVID-19 pandemic as food insecurity possesses a considerable health threat to all.

An undergraduate medical curriculum framework for providing care to transgender and gender diverse patients: A modified Delphi study

INTRODUCTION

The lack of attention to transgender and gender diverse (TGD) people in undergraduate medical education (UME) is a point of concern, particularly among medical students. A project was undertaken to develop a UME curriculum framework for teaching the healthcare needs of TGD people.

METHODS

Using a modified Delphi methodology, four rounds of surveys were presented to an expert stakeholder group that included content experts, generalist physicians, UME teaching faculty, and medical students. Questions covered what content should be taught, who should teach the content, and how much time should be dedicated for this teaching. Once the Delphi process was complete, feedback on the provisional framework was sought from members of the TGD community to ensure it represented their needs and perspectives.

RESULTS

71 panel members and 56 community members participated in the study. Core values included the scope of the framework, and topics such as inclusivity, and safety in practice and in teaching. The framework included terminology, epidemiology, medical and surgical treatment, mental health, sexual and reproductive health, and routine primary care. There was also guidance on who should teach, time to be allocated, and the learning environment.

DISCUSSION

There is a clear need to train tomorrow's doctors to provide competent and respectful healthcare services to and for TGD patients. Although local factors will likely shape the way in which this framework will be implemented in different contexts, this paper outlines a core UME-level curriculum framework for Canada and, potentially, for use in other parts of the world.

Examining the Mental Health Presentations of Treatment-Seeking Transgender and Gender Nonconforming (TGNC) Youth

Recent research suggests that transgender and/or gender nonconforming (TGNC) youth present with heightened levels of mental health problems compared to peers. This study seeks to examine the mental health needs of a large sample of treatment-seeking TGNC youth by comparing them to cisgender males and females. Participants were 94,804 children and youth ages 4-18 years (M = 12.1, SD = 3.72) who completed the interRAI Child and Youth Mental Health Instrument (ChYMH) or Screener (ChYMH-S) at participating mental health agencies in the Ontario, Canada. Overall, the mental health presentations of TGNC youth were similar to cisgender females but at higher acuity levels. TGNC youth showed significantly higher levels of anxiety, depression, social disengagement, positive symptoms, risk of suicide/self-harm, and were more likely to report experiencing emotional abuse, past suicide attempts, and a less strong, supportive family relationship than cisgender females and males. Clinical implications of these findings are discussed.

Expanding the limits of sex: a systematic review concerning food and nutrition in transgender populations

OBJECTIVE

To examine the literature and identify main themes, methods and results of studies concerning food and nutrition addressed in research on transgender populations.

DESIGN

A systematic review conducted through July 2020 in the MedLine/PubMed, Scopus and Web of Science databases.

RESULTS

Of the 778 studies identified in the databases, we selected thirty-seven. The studies were recent, most of them published after 2015, being produced in Global North countries. The most often used study design was cross-sectional; the least frequently used study design was ethnographic. Body image and weight control were predominant themes (n 25), followed by food and nutrition security (n 5), nutritional status (n 5), nutritional health assistance (n 1) and emic visions of healthy eating (n 1).

CONCLUSIONS

The transgender community presents body, food and nutritional relationships traversed by its unique gender experience, which challenges dietary and nutritional recommendations based on the traditional division by sex (male and female). We need to complete the lacking research and understand contexts in the Global South, strategically investing in exploratory-ethnographic research, to develop categories of analysis and recommendations that consider the transgender experience.

Sex and gender differences in nutrition research: considerations with the transgender and gender nonconforming population

A sex- and gender-informed approach to study design, analysis and reporting has particular relevance to the transgender and gender nonconforming population (TGNC) where sex and gender identity differ. Notable research gaps persist related to dietary intake, validity and reliability of nutrition assessment methods, and nutrition interventions with TGNC populations. This is due in part to the conflation of sex and gender into one binary category (male or female) in many nutrition surveillance programs worldwide. Adoption of the Sex and Gender Equity In Research (SAGER) guidelines and the two-step method of querying sex and gender has the potential to exponentially increase the body of research related to TGNC health.

How Are Transgender and Gender Nonconforming Youth Affected by the News? A Qualitative Study

PURPOSE

News stories about transgender and gender nonconforming (TGNC) people have become more common in recent years and TGNC youth may be disparately affected by this information compared with their cisgender peers. The aim of this study was to understand how TGNC youth react to news stories about TGNC and other gender and sexual minority (GSM) identifying persons.

METHODS

As part of a larger study, 23 TGNC youth were recruited from the Seattle Children's Gender Clinic to participate in a semistructured interview. Interviews were audio recorded, transcribed, and thematically analyzed.

RESULTS

Participating youth ranged in age from 13 to 19 years (mean = 16.9 years). Of the 23 participants, 43% identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Four main themes were identified: (1) news coverage of current political climate affects gender transition; (2) negative news coverage of GSM people contributes to concerns about mental well-being and safety; (3) geographical location affects perception of news; and (4) positive news coverage of TGNC people increases visibility and hope.

CONCLUSIONS

Exposure to negative news about GSM people may contribute to increased levels of stress among TGNC youth. With increased visibility, participants described frustration associated with inaccurate portrayals of the TGNC community in the news; however, with increased visibility, there is also a growing sense of shared community and opportunity for acceptance of TGNC people. Given the scope of responses to negative and positive news on GSM people, TGNC youth may benefit from increased support to promote resilience when interpreting the news.

Rural living environment predicts social anxiety in transgender and gender nonconforming individuals across Canada and the United States

Transgender and gender nonconforming (TGNC) individuals frequently confront discrimination, rejection, and violence. Such experiences may put TGNC individuals at risk for minority stress and associated psychiatric symptoms. Protective factors like social support, pride in one's gender identity, or connectedness to similar others may make TGNC individuals less vulnerable to psychiatric symptoms, and the presence of risk and protective factors may vary depending on living environment. This study examined the relationship of living environment (urban vs. suburban vs. small-town/rural) to social anxiety (SA) in a sample of 902 TGNC individuals who participated in the Trans Health Survey. Analysis of variance revealed a significant difference in SA across living environments. Those living in small-town/rural environments reported significantly higher levels of SA compared to those living in urban environments. There was a trend-level difference in SA in suburban compared to urban environments. Linear regression analyses revealed that living environment significantly moderated the relationship between social support and SA. Higher social support was more protective against elevated SA in urban and suburban than in small-town/rural environments. This study is the first to demonstrate the experience of elevated SA among TGNC individuals living in rural environments. Implications and future directions for research are discussed.

Size and Distribution of Transgender and Gender Nonconforming Populations: A Narrative Review

Accurate estimates of the number and proportion of transgender and gender nonconforming people in a population are necessary for developing data-based policy and for planning and funding of health care delivery and research. The wide range of estimates reported in the literature is attributable primarily to differences in definitions. Other sources of variability include diverse cultural and geographic settings and important secular trends. The transgender and gender nonconforming population is undergoing rapid changes in size and demographic characteristics. More accurate and precise estimates will be available when population censuses collect data on sex assigned at birth and gender identity.

Primary Care for the Transgender and Gender Nonconforming Patient

All physicians are likely to encounter gender diverse patients, and some of these patients require medically necessary surgical procedures. It is optimal for surgeons to collaborate with other providers who interact with this patient population. Primary care physicians initiate treatment with consultation from mental health professionals and refer to surgeons when necessary. Best practices consist of preventative care, hormone therapy induction when indicated, monitoring of all health parameters, and continuing care medically and postoperatively.

Past and Future Challenges Associated with Standards of Care for Gender Transitioning Clients

This article defines a standard of care, describes their purpose in general, and then provides an overview of the World Professional Association for Transgender Health's Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People Version 7. After a brief history of the document, past and future challenges associated with these Standards including ideas moving forward into the eighth version are presented.

Working Toward Family Attunement: Family Therapy with Transgender and Gender-Nonconforming Children and Adolescents

Families of transgender and gender-nonconforming youth often seek therapy for assistance in understanding, accepting, and supporting their child. This article describes a gender-affirmative approach to family therapy and outlines strategies for addressing common challenges faced by the families of transgender and gender-nonconforming youth. Therapy begins by assessing family attunement and working with parents, siblings, and other family members to better support the youth. Once family attunement is achieved, therapy can begin to explore options for gender expression and/or transition. The therapeutic model is illustrated by applying it to case examples.

Affirmative Cognitive Behavior Therapy with Transgender and Gender Nonconforming Adults

Although there is growing awareness in contemporary society regarding transgender and gender nonconforming (TGNC) identities, transgender people continue to be highly marginalized and subject to transphobic discrimination and victimization. As a result, authentically expressing and navigating a TGNC identity can be difficult. Psychiatrists and other mental health professionals can play a key role in supporting TGNC client health and well-being through the use of trans-affirmative approaches. Trans-affirmative practice recognizes all experiences of gender as equally healthy and valuable This article focuses on transgender affirmative cognitive behavior therapy.

Transgender youth: current concepts

In many countries throughout the world, increasing numbers of gender nonconforming/transgender youth are seeking medical services to enable the development of physical characteristics consistent with their experienced gender. Such medical services include use of agents to block endogenous puberty at Tanner stage II with subsequent use of cross-sex hormones, and are based on longitudinal studies demonstrating that those individuals who were first identified as gender dysphoric in early or middle childhood and continue to meet the mental health criteria for being transgender at early puberty are likely to be transgender as adults. This review addresses terms and definitions applicable to gender nonconforming youth, studies that shed light on the biologic determinants of gender identity, current clinical practice guidelines for transgender youth, challenges to optimal care, and priorities for research.

Human Immunodeficiency Virus, Other Sexually Transmitted Infections, and Sexual and Reproductive Health in Lesbian, Gay, Bisexual, Transgender Youth

Lesbian, gay, bisexual, transgender (LGBT), and questioning youth represent a diverse population who are affected by many sexual health inequities, including increased risk for human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). To provide comprehensive sexual health care for LGBT youth, providers should set the stage with a nonjudgmental, respectful tone. Providers should be competent in recognizing symptoms of STIs and HIV and aware of the most up-to-date screening guidelines for LGBT youth. Sexual health visits should also focus on prevention, including safer sex practices, HIV pre-exposure and post-exposure prophylaxis, family planning, and immunization for hepatitis and human papillomavirus.