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

Young adults from disadvantaged groups experience more stress and deterioration in mental health associated with polycrisis

The recent polycrisis (COVID-19, Ukraine war, climate change, economic crisis) has been associated with mental health through cumulative stress, with young people being particularly vulnerable. We surveyed 403 college students from Poland to examine their psychological responses to the experienced crises. The results showed that polycrisis was associated with worse mental health of college students from disadvantaged groups (based on gender, sexual orientation, and financial situation) compared to other college students, in four areas: sense of proximity to the crises, stress caused by the crises, sense of responsibility for mitigating the crises, and experiencing everyday moral dilemmas regarding the crises. These young adults also suffered more in terms of negative affectivity, depressive symptoms, and subjective physical and mental health. Our findings suggest that when discussing public mental health perspectives, it is important to consider consequences of cumulative stress and its greater impact on young people from disadvantaged groups.

Describing Non-Binary People's Encounters with the Healthcare System: A Qualitative Study in Catalonia (Spain)

Non-binary people face numerous stressors in their daily lives, including personal, interpersonal, and environmental. These stressors gain strength when such individuals access healthcare services, and discrimination and cisgenderism become the main barrier to obtaining gender-affirming healthcare. This study aimed to describe the experiences of non-binary people regarding the care and medical attention received in Catalonia (Spain). A qualitative phenomenological study was conducted with 21 non-binary people recruited using snowball sampling in 2022. Data were gathered through open-ended interviews and analyzed using thematic analysis. Two main themes were identified, which were further classified into two categories each: Theme 1-This is me composed of the categories, "My Name and My Pronouns" and "One's Chosen Gender," and Theme 2-I do not exist for the health system consisting of "Uneducated Health System in Sexual Health" and "Feeling Like an Outsider for Being Non-Binary." Non-binary people face multiple stressors when accessing the healthcare services that makes them feel invisible, vulnerable, and marginalized. Further widespread implementation of person-centered care is essential to promote the relationship between non-binary people and the healthcare system. In addition, further sexual health training is required for all health professionals.

Autistic Traits, Gender Minority Stress, and Mental Health in Transgender and Non-Binary Adults

The present study investigated the relation between autistic traits and gender minority stress and the relative importance of autistic traits and gender minority stress in predicting mental health outcomes in gender minority adults. An online survey was completed by 90 transgender women, 72 transgender men, 48 non-binary individuals assigned male at birth (AMAB), and 98 non-binary individuals assigned female at birth (AFAB). Autistic traits positively correlated with internalised transphobia in the non-binary groups. In general, higher autistic traits and gender minority stress correlated with poorer mental health outcomes. After controlling for gender minority stress, autistic traits accounted for additional variance of suicidality across gender minority groups, anxiety symptoms in the non-binary groups, and all mental health outcomes in non-binary AFAB.

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.

Analyzing body dissatisfaction and gender dysphoria in the context of minority stress among transgender adolescents

BACKGROUND

Gender dysphoria among transgender adolescents has predominantly been examined in relation to body dissatisfaction. While in adult transgender samples, body dissatisfaction is higher than in cisgender controls, this has so far rarely been investigated for adolescents. In the context of a cisnormative society, the impact of influences from the social environment on body dissatisfaction and gender dysphoria has been neglected in research. Therefore, this study aimed to (1) provide a detailed analysis of body dissatisfaction among young transgender people and (2) investigate whether body dissatisfaction and gender dysphoria are associated with experiences of minority stress such as trans hostility and poor peer relations (PPR).

METHODS

The paper presents a cross-sectional study among a sample of transgender adolescents, presenting at a specialized outpatient counseling clinic (N = 99; age M = 15.36, SD = 1.85). First, body dissatisfaction (assessed by the Body-Image-Scale; BIS), was explored and compared to data from a population-based control group of cisgender peers (N = 527; age M = 14.43, SD = 0.97). Second, within a clinic-referred transgender subsample (n = 74), associations between body dissatisfaction and gender dysphoria (measured by Utrecht Gender Dysphoria Scale; UGDS), PPR (measured by the Youth-Self-Report; YSR-R), and trans hostile experiences (assessed in clinical interview) were examined by correlations, t-tests and multivariate regression.

RESULTS

Transgender adolescents reported more body dissatisfaction than cisgender peers. The dissatisfaction with sex characteristics, non-hormonal reactive body regions and the total score for body dissatisfaction were positively related with gender dysphoria. The majority had experienced trans hostility in the present and/or past (54.1%) and PPR (63.5%). More body dissatisfaction was correlated with more PPR regarding visible body parts i.e., hair, overall appearance and muscles, whilst PPR and gender dysphoria were not associated. Transgender adolescents who experienced trans hostility showed higher gender dysphoria and PPR, but not more body dissatisfaction. In multiple regression, trans hostility predicted gender dysphoria, whilst age and PPR predicted body dissatisfaction.

DISCUSSION

Experiences of minority-stress differentially interact with body dissatisfaction and gender dysphoria among transgender adolescents. Social correlates of body dissatisfaction and gender dysphoria must be considered when working with young transgender people.

Binary and Non-binary Gender Identities, Internalizing Problems, and Treatment Wishes Among Adolescents Referred to a Gender Identity Clinic in Germany

Clinical research on transgender and gender-nonconforming (TGNC) adolescents has focused on binary individuals or often not differentiated among gender identities. Recent studies suggest that a considerable proportion of TGNC adolescents identify as non-binary and that these youth report more internalizing problems as well as different transition-related medical treatment wishes than binary adolescents. However, the results are inconclusive, and data for the German-speaking area are lacking. Therefore, the present study aimed to assess the percentage of binary and non-binary gender identities in a German sample of clinically referred TGNC adolescents and examine associations of gender identity with internalizing problems and transition-related medical treatment wishes. The sample consisted of 369 adolescents (11-18 years, Mage = 15.43; 305 birth-assigned female, 64 birth-assigned male) who attended the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS) between 2013 and 2019. Gender identity and treatment wishes were assessed using study-specific items and internalizing problems using the Youth Self-Report. In total, 90% (n = 332) of the sample identified as binary and 10% (n = 37) as non-binary. Having a non-binary gender identity was significantly associated with more internalizing problems and with wishing for no transition-related medical treatment or only puberty-suppressing hormones. The results underscore that non-binary adolescents represent a specifically vulnerable subgroup within TGNC adolescents with unique mental health needs and treatment wishes. Future research should differentiate among various gender identities. In clinical practice, it is crucial to create an inclusive space for non-binary youth and provide mental health care if needed.

[Gender Experiences of Transgender Youth: How Changeable is the Gender Experience of Binary vs. Nonbinary Identifying Transgender Youth and What Factors Are Involved?]

Gender Experiences of Transgender Youth: How Changeable is the Gender Experience of Binary vs. Nonbinary Identifying Transgender Youth and What Factors Are Involved? Abstract: Objectives: Nonbinary gender identities are becoming increasingly visible in transgender healthcare and research. However, little is known about the various gender identities of transgender adolescents - whether they are stable or fluid and which factors influence their gender experience. The present study investigates these different aspects of gender in transgender adolescents with various gender identities. Method: The sample comprised a recent cohort of 114 adolescents diagnosed with gender dysphoria (GD) attending the Hamburg Gender Identity Service for Children and Adolescents (Hamburg GIS). We used the Gender Diversity Questionnaire to assess the different aspects of gender. Results: In total, 83 % of the sample reported a binary (BI) and 17 % a nonbinary gender identity or were still questioning their gender identity (NBGQ). 15-18 % of the transgender adolescents reported gender fluidity. The NBGQ group reported significantly higher levels of gender fluidity or more often that their gender identity was still open to change, respectively, than the BI group. Puberty (79 %), physical distress (70 %), and social media (36 %) were the most frequently mentioned factors influencing their gender experience. Conclusions: The present study underscores that gender experience is not binary and fixed for all transgender adolescents, but that, in some cases, it may be nonbinary or fluid. This heterogeneity, the possible fluidity, and the puberty-related physical distress may challenge treatment decisions in transgender adolescents diagnosed with GD. This situation highlights the importance of developing individualized treatment plans.

Social Support for Rural Gender Diverse Youth Compared to Cisgender Peers

PURPOSE

Gender diverse youth (GDY) experience higher rates of mental health concerns than their cisgender peers, but these can be ameliorated by feeling support from family, school, and community. Little is known about how youth perceptions of support vary by gender identity, especially for younger adolescents and those living in rural areas.

METHODS

Youth ages 12-19 years completed anonymous surveys including measures of perceived support and a two-step gender identity question. GDY (n = 206) were further categorized into binary and nonbinary gender identities. An additional 500 randomly selected cisgender youth were included for comparison. Multivariate analyses of variance with Tukey post hoc tests were employed to test GDY group differences while accounting for the interaction between scaled measures.

RESULTS

Cisgender youth had the highest perceived support across all support measures while youth who shared both binary and nonbinary aspects of their gender identity had the lowest rates of perceived support. The F tests for between-subject effects were statistically significant (p <.001) for all six support measures, and multivariate group testing was statistically significant with Wilks' λ 6.38(18,1621.17) = 0.82; p <.001.

DISCUSSION

Despite research demonstrating a strong association between perceived support and improved mental health outcomes, GDY in our sample had lower rates of perceived support at the family, school, and community levels. GDY with both binary and nonbinary gender identities had the lowest levels of perceived support. Further research is needed to see if this finding is consistent in other populations and to develop targeted interventions to improve perceived support for this population.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

The Role of Family Support and Dyadic Adjustment on the Psychological Well-being of Transgender Individuals: An Exploratory Study

Introduction

This study aimed to measure dyadic adjustment, social support, and psychological well-being.

Methods

A research protocol composed of the Dyadic Adjustment Scale, the Outcome Questionnaire 45.2, and the Multidimensional Scale of Perceived Social Support was administered to a sample of 109 Italian transgender individuals.

Results

Higher levels of global psychological distress, symptom severity, and interpersonal relationship distress were associated with lower levels of family support and dyadic adjustment. In addition, transgender women and younger transgender individuals reported higher levels of interpersonal relationship distress.

Conclusions

The results indicate that the support and acceptance of one's partner and family of origin play a crucial role in promoting well-being. It represents an important protective factor with respect to negative psychological health outcomes.

Policy Implications

The findings emphasize the need to develop specific clinical and social practices for transgender individuals and their families. Building family and partner-centered policies and programs is particularly important to enable transgender individuals to avoid paying the emotional and psychological costs associated with rejection and non-acceptance.

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.

Associations Among Gender-Affirming Hormonal Interventions, Social Support, and Transgender Adolescents' Mental Health

PURPOSE

We aimed to examine the concurrent associations of gender-affirming hormonal interventions (i.e., puberty blockers, testosterone, estrogen), as well as family and friend social support, on transgender and nonbinary (TNB) adolescents' reports of anxiety symptoms, depressive symptoms, nonsuicidal self-injury (NSSI), and suicidality. We hypothesized that gender-affirming hormonal interventions and greater social support would be associated with lower levels of mental health concerns.

METHODS

Participants (n = 75; aged 11-18; M_age = 16.39 years) were recruited for this cross-sectional study from a gender-affirming multidisciplinary clinic. Fifty-two percent were receiving gender-affirming hormonal interventions. Surveys assessed anxiety and depressive symptoms, NSSI and suicidality in the past year, and social support from family, friends, and significant others. Hierarchical linear regression models examined associations between gender-affirming hormonal interventions and social support (i.e., family, friend) with mental health while accounting for nonbinary gender identity.

RESULTS

Regression models explained 15%-23% of variance in TNB adolescents' mental health outcomes. Gender-affirming hormonal interventions were associated with fewer anxiety symptoms (β = -0.23; p < .05). Family support was associated with fewer depressive symptoms (β = -0.33; p = .003) and less NSSI (β = -0.27; p = .02). Friend support was associated with fewer anxiety symptoms (β = -0.32; p = .007) and less suicidality (β = -0.25; p = .03).

DISCUSSION

TNB adolescents had better mental health outcomes in the context of receiving gender-affirming hormonal interventions and having greater support from family and friends. Findings highlight the important role of quality family and friend support for TNB mental health. Providers should aim to address both medical and social factors to optimize TNB mental health outcomes.

Gender-Affirming Care and Comprehensive Sexuality Education

ABSTRACT

Every year, an estimated 246 million children are subject to some form of gender-based violence, including mistreatment, bullying, psychological abuse, and sexual harassment. Lesbian, gay, bisexual, transgender, two-spirit, or questioning youth are at a heightened risk of experiencing violence and have unique health, educational, and social needs. Fostering an atmosphere of support and acceptance can help alleviate many of these negative outcomes.

Predictors of self-harm and suicide in LGBT youth: The role of gender, socio-economic status, bullying and school experience

BACKGROUND

Lesbian, gay and bisexual (LGB) young people's increased risk of self-harm, suicidal attempts and suicide compared with heterosexual youth is well established. The current study sought to examine whether these findings also apply to the trans (T) population and which factors act as additional risk or protective factors.

METHODS

In a national cross-sectional survey, 3713 LGBT adolescents, aged 11-19 years, reported on their own history of self-harm, suicidal ideation and suicide attempts, as well as their experiences of school and homophobic, biphobic and transphobic bullying. Logistic regressions tested the association between risk and protective factors on self-harm, suicidal ideation and suicide attempts.

RESULTS

A high proportion of the sample reported self-harm (65.3%), suicidal ideation (73.8%) and suicide attempts (25.7%). Demographic risk factors included identifying as female, non-binary or trans and being from a low-income background. Bullying and online bullying were associated with an increased risk for each outcome, and positive school experience was associated with a reduced risk for each outcome.

CONCLUSIONS

Consistent with minority stress theory, the study found high rates of mental health problems within LGBT youth. Interventions focused on improving young people's experiences in schools appear useful targets to help improve mental health outcomes.

Social Support and Mental Health Among Transgender and Nonbinary Youth in Quebec

Purpose: Transgender and nonbinary (TNB) youth face elevated levels of discrimination, stigma, mental health disorders, and suicidality when compared with their cisgender counterparts. Family and school support may mitigate some of the effects of the stressors facing TNB youth. This study aimed to better understand the impact of each of these sources of support on TNB youths' mental health and wellbeing. Methods: We used data collected between 2018 and 2019 as part of the Canadian Trans Youth Health Survey, a bilingual online survey to measure social support, physical health, and mental health in a sample of 220 TNB youth aged 14-25 living in Québec, Canada. We examined the relationships among different sources of support, and mental health and wellbeing outcomes using logistic regression. Analyses were conducted on the full sample and according to linguistic groups (French and English). Results: Participants reported high levels of mental health symptoms, self-harm, and suicidality, and mental health symptoms were higher in the English-speaking group (p = 0.005). In models controlling for age, family connectedness was associated with good/excellent self-reported mental health (odds ratio [OR] = 2.62, p = 0.001) and lower odds of having considered suicide (OR = 0.49, p = 0.003) or attempted suicide (OR = 0.43, p = 0.002), whereas school connectedness was associated with higher odds of good/very good/excellent general (OR = 2.42, p = 0.013) and good/excellent mental (OR = 2.45, p = 0.045) health. Conclusion: Family and school support present consistent associations with TNB youths' health and may constitute key areas for intervention for those supporting them.

Changes in Stress, Depression, and Anxiety Symptoms in a Brazilian Sample During Quarantine Across the Early Phases of the COVID-19 Crisis

OBJECTIVE

We aimed to estimate prevalence and incidence of stress, depression, and anxiety symptoms in Brazilians during the COVID-19 pandemic.

METHOD

We assessed 103 (54 women, 49 men) participants online in three periods of the pandemic: March 2020 (T1), April 2020 (T2), and June 2020 (T3). Estimates of prevalence and incidence were identified when mental health scores were two standard deviations above the mean compared to normative data. Mental health indicators were measured using the Perceived Stress Scale, the Filgueiras Depression Index, and the State-Trait Anxiety Inventory - State Subscale.

RESULTS

At T1, 89% of individuals were below cut-off scores for stress, anxiety, and depression, which dropped to 35% by T3. Estimated stress prevalence was 1.9% at T1, 7.8% at T2, and 28.2% at T3. Estimated depression prevalence was 0% at T1, 23.3% at T2, and 25.2% at T3. Estimated state anxiety prevalence was 10.7% at T1, 11.7% at T2, and 45.6% at T3. Stress incidence increased by 7.8% from T1 to T2, and 23.3% from T2 to T3. Depression incidence increased by 23.3% from T1 to T2, and 15.5% from T2 to T3. Anxiety incidence increased by 9.7% from T1 to T2, and 39.8% from T2 to T3. Stress severity scores significantly increased from 16.1 ± 8.7 at T1 to 23.5 ± 8.4 at T2, and 30.3 ± 6.0 at T3. Depression severity scores significantly increased from 48.5 ± 20.5 at T1 to 64.7 ± 30.2 at T2, and 75.9 ± 26.1 at T3. Anxiety increased from 49.0 ± 13.4 at T1 to 53.5 ± 12.5 at T2 and 62.3 ± 13.4 at T3. Females had significantly higher anxiety scores than males by T3 (66.7 ± 11.8 vs. 57.4 ± 13.5).

CONCLUSION

Prevalence and incidence of stress, depression, and anxiety significantly increased throughout the pandemic. The largest increase in stress and anxiety occurred between T2 and T3, and between T1 and T2 for depression. Severity of stress, depression, and anxiety increased throughout the study.

Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients

BACKGROUND

Transgender and gender diverse (TGD) individuals experience more severe psychological distress and may be at higher risk for suicide compared to cisgender individuals. The existing literature largely consists of small-sample studies that do not assess subgroup differences.

OBJECTIVE

To examine rates of self-reported suicidal ideation among four TGD groups compared to cisgender individuals.

DESIGN

Data were extracted from the electronic health records of patients receiving primary care at a community health center specializing in sexual and gender minority health. A logistic regression was used to examine the relationship between sociodemographic variables and the presence of current suicidal ideation.

PARTICIPANTS

29,988 patients receiving care at a community health center in Northeastern US between 2015 and 2018.

MAIN MEASURES

Demographic questionnaire, 9-item Patient Health Questionnaire KEY RESULTS: Younger age, sexual and gender minority identity, and public/grants-based insurance were associated with significantly higher odds of suicidal ideation. Relative to cisgender men, transgender men (OR=2.08; 95% CI=1.29-3.36; p=.003), transgender women (OR=3.08; 95% CI=2.05-4.63; p<.001), nonbinary (NB) individuals assigned male at birth (AMAB; OR=3.55; 95% CI=1.86-6.77; p<001), and NB individuals assigned female at birth (AFAB; OR=2.49; 95% CI=1.52-4.07; p<001) all endorsed significantly higher odds of current suicidal ideation, controlling for age, race, ethnicity, sexual orientation, and insurance status. Larger proportions of transgender women (23.6%) and NB AMAB individuals (26.7%) reported suicidal ideation not only compared to cisgender men (6.1%) and women (6.6%), but also compared to transgender men (17.4%; χ²[5, n=25,959]=906.454, p<0.001).

CONCLUSIONS

TGD patients were at significantly increased risk of suicidal ideation, even after accounting for age, race, ethnicity, sexual orientation, and insurance status. Findings suggest distinct risk profiles by assigned sex at birth. Consistent assessment of and intervention for suicidal ideation should be prioritized in settings that serve TGD patients.

The moderating effect of physical activity on the relationship between bullying and mental health among sexual and gender minority youth

BACKGROUND

Sexual and gender minority youth frequently experience bullying, which often contributes to higher depressive symptoms and lower self-esteem. Given that physical activity (PA) can mitigate depressive symptoms and improve self-esteem, we examined the moderating effect of PA on the relationship between bullying and mental health among sexual and gender minority youth.

METHODS

Data from the Lesbian, Gay, Bisexual, Transgender, and Queer National Teen Survey (n = 9890) were analyzed. Hierarchical regression analyses examined the influence of history and frequency of being bullied, PA, and the interaction of these variables on depressive symptoms and self-esteem. Simple slopes analyses were used to probe significant interactions.

RESULTS

Results indicated the importance of accounting for bullying history when examining effects of PA on mental health. PA was negatively related to depression (t = -4.18, p < 0.001) and positively related to self-esteem (t = 12.11, p < 0.001). Bullying frequency was positively related to depression (t = 19.35, p < 0.001) and negatively related to self-esteem (t = -12.46, p < 0.001). There was a significant interaction between bullying frequency and PA for depression (t = 4.45, p < 0.001) and self-esteem (t = -4.69, p < 0.001). Post hoc analyses suggested that the positive effects of PA on mental health may be limited to those not bullied because it had a negligible effect on those who were bullied.

CONCLUSION

Results suggest that sexual and gender minority youth exercise interventions aiming to improve mental health should first address bullying history; otherwise, their effectiveness may be limited to those who have been bullied.

Social Support as a Buffer of the Association between Sexual Assault and Trauma Symptoms Among Transgender and Gender Diverse Individuals

The prevalence of experiencing sexual assault is alarmingly high among Transgender and Gender Diverse people (TGD; people whose gender identities and/or expressions are not traditionally associated with their sex assigned at birth) and is associated with various mental health sequalae. Perceived social support has been shown to abate the negative outcomes of sexual assault among cisgender individuals, yet little is known about this association among TGD people, especially which provider of support (i.e., family, friends, or significant others) may be most beneficial. To that end, 191 TGD adults were recruited through Amazon's Mechanical Turk to examine perceived social support as a potential moderator of the association between sexual assault victimization and post-sexual assault trauma symptomology. Results showed an interaction trending toward significance between sexual assault and support from a significant other. Decomposition of this interaction demonstrated that sexual assault was associated with post-assault trauma symptoms when support from a significant other was low (ß = .25, p < .05) but not high (ß = .10, p = .089). The interaction between sexual assault and perceived social support was not significant for perceived support from friends (p = .133) or family (p = .954). Findings highlight the need for additional research on perceived social support as a potential buffering mechanism between sexual assault and post-assault symptomology in TGD people.

Sex Chromosome Rearrangement Associated With Hormonal Abnormalities and Gender Dysphoria

Although disorders arising from sex chromosome and sex steroid abnormalities are well characterized from the perspectives of endocrinology, dysmorphology, and reproductive health, relatively little is known about neuropsychiatric development, gender identity, incongruence, and dysphoria in the populations with these disorders. In this report, we describe the case of a 21-year-old gender nonbinary individual identified as male at birth who presented to an academic psychiatry consultation clinic because of life-long gender dysphoria. The patient was found to have a complex sex chromosomal rearrangement and associated hormonal abnormalities that may, at least in part, explain the patient's history. In addition to describing a novel genetic change, this case and the accompanying review of the existing literature highlight the need for an increased focus on the psychiatric perspective, and sex and gender issues in particular, among all patients with sex chromosome abnormalities and inborn errors of steroid metabolism.

Gender-affirming endocrine care for youth with a nonbinary gender identity

Nonbinary individuals, or those who identify outside of the traditional gender binary, are currently present in up to 9% of the general population of youth or up to 55% of gender-diverse youth. Despite the high numbers of nonbinary individuals, this population continues to experience barriers to healthcare due to providers' inability to see beyond the transgender binary and lack of competence in providing nonbinary care. In this narrative review, we discuss using embodiment goals to individualize care of nonbinary individuals, and review hormonal and nonhormonal treatment options for gender affirmation. Hormonal treatments include those often used in binary transgender individuals, such as testosterone, estradiol, and anti-androgens, but with adjustments to dosing or timeline to best meet a nonbinary individual's embodiment goals. Less commonly used medications such as selective estrogen receptor antagonists are also discussed. For nonhormonal options, alterations in gender expression such as chest binding, tucking and packing genitalia, and voice training may be beneficial, as well as gender-affirming surgeries. Many of these treatments lack research specific to nonbinary individuals and especially nonbinary youth, and future research is needed to ensure safety and efficacy of gender-affirming care in this population.

Non-Binary Clients' Experiences of Psychotherapy: Uncomfortable and Affirmative Approaches

Non-binary people may face specific challenges in psychological settings. Psychotherapists often display a lack of preparation for non-binary gender identities, resulting in overt or subtle forms of prejudice that compromise the therapeutic alliance. The present study aimed to provide data on non-binary clients' positive and negative experiences within therapeutic relationships. Twenty-five interviews were conducted with non-binary people in the age range of 19-35. Using codebook thematic analysis, the researchers identified three main themes: (1) the self of the psychotherapist, consisting of the impact of the therapist's personal (i.e., sexual identity) and professional (i.e., competence) characteristics on the therapeutic experience; (2) the practice of the psychotherapist, emerging as affirmative (validation and microaffirmations) or negative (gender identity change efforts, manifest aggressions, and microaggressions) approaches toward non-binary identities; (3) the therapeutic relationship, referring to the alliance, rupture, and reparation based on the therapists' openness toward non-binary identities. To provide a safer setting for non-binary clients, psychotherapists should incorporate issues related to gender minority identities in their training, acknowledge clinical errors when they occur and adopt an active predisposition to learn through the client's experience, giving value to their unique contribution.

Mental health among sexual and gender minorities: A Finnish population-based study of anxiety and depression discrepancies between individuals of diverse sexual orientations and gender minorities and the majority population

Substantial empirical evidence suggests that individuals who belong to sexual and gender minorities experience more anxiety and depression than heterosexual and cisgender people. Many previous studies have not, however, used population-based samples. There is also a shortage of evidence about certain sexual and gender minorities (e.g., nonbinary individuals). We examined differences in levels of anxiety and depression within sexual and gender minorities, as well as compared to the heterosexual and cisgender majority in a population-based Finnish sample (N = 8,589). We also explored if individuals who belong to both a gender and a sexual minority (double minority) reported higher rates of anxiety and depression than individuals who hold either a gender or a sexual minority status (single minority). Individuals who belonged to either a sexual or a gender minority overall experienced significantly higher rates of anxiety and depression than cisgender and heterosexual individuals. Among the different sexual and gender minorities, bisexual, emerging identity, and nonbinary individuals reported the highest rates of anxiety and depression. We found no differences in anxiety and depression between single minority and double minority individuals. Our results suggest that even though Finland is a country with an inclusive social climate, sexual and gender minorities are, nevertheless, disproportionately affected by mental health issues. The present study gives further support to the claim that individuals holding a sexual or gender minority status experience higher levels of depression and anxiety compared to cisgender and heterosexual individuals and pinpoints the need to acknowledge these issues both in the context of health care and in the society at large.

Body image and treatment desires at clinical entry in non-binary and genderqueer adults

Background: Gender clinics are experiencing an increase in non-binary and/or genderqueer (NBGQ) individuals applying for gender affirming medical treatment (GAMT). GAMT is a well-established approach in reducing body dissatisfaction in binary transgender (BT) people, but knowledge on GAMT in NBGQ people is limited. Previous research shows that NBGQ individuals report different treatment needs compared to BT individuals. In attempting to address this difference, the current study examines the association between identifying as NBGQ, body dissatisfaction and their underlying motives for GAMT. The main research objectives were to describe the desires and motives for GAMT in NBGQ people and to examine how body dissatisfaction and gender identity relate to one's request for GAMT. Methods: Online self-report questionnaires were administered on 850 adults referred to a gender identity clinic (Mdn age = 23.9 years). Gender identity and desires for GAMT were surveyed at clinical entry. Body satisfaction was assessed with the Body Image Scale (BIS). Multiple linear regressions were used to examine whether BIS scores differed between NBGQ and BT individuals. Chi-square post hoc analyses were used to identify differences in treatment desires and motives between BT and NBGQ individuals. Logistic regressions were conducted to study the association between body image, gender identity and treatment desire. Results: Compared to BT persons (n = 729), NBGQ persons (n = 121) reported less body dissatisfaction, primarily with the genital area. NBGQ persons also preferred fewer GAMT interventions. If a procedure was not desired, NBGQ individuals more often motivated this on the basis of their gender identity, while BT individuals more often cited the risks of the procedure as their primary reason. The study confirms the need for more NBGQ specialized care, as they have a distinct experience of their gender incongruence, physical distress and express specific needs in GAMT.

Sexuality and Gender Identity Inequities in Substance Use Disorder and Its Treatment among American Indian, Alaska Native, and Native Hawaiian College Students

BACKGROUND

The aim of this study was to investigate inequities in substance use disorder (SUD) diagnosis, opioid misuse, marijuana misuse, SUD treatment utilization, and utilization of university mental health services among sexual and gender minority (SGM) American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) college students.

METHODS

Data consisting of 8,103 AI/AN/NH students' responses to the American College Health Association's National College Health Assessment survey from fall 2015 through spring 2019 were utilized for this study. Multivariable logistic regression models were used to compare the odds of SUD diagnosis, opioid misuse, and marijuana misuse in SGM AI/AN/NH students to cisgender, heterosexual peers. Unadjusted odds of SUD treatment utilization and utilization of university mental health services were also evaluated.

RESULTS

Compared to cisgender females, transgender (aOR = 4.43, 95% CI = 2.67-7.34) and gender diverse (aOR = 2.86, 95% CI = 1.61-5.07) students had significantly higher odds of SUD diagnosis. Similarly, significantly higher odds of SUD diagnosis were observed among sexual minorities, including gay/lesbian (aOR = 2.95, 95% CI = 1.71-5.09) and bisexual (aOR = 1.97, 95% CI = 1.30-2.99) students compared to heterosexual peers. Sexual minority students had significantly higher odds of utilizing university mental health services (uOR = 2.43, 95% CI = 1.22-4.84) than heterosexual peers. Odds of opioid misuse and marijuana misuse were also significantly increased among sexual minority students.

CONCLUSIONS

AI/AN/NH college students who identify as SGM have higher odds of SUD diagnosis, opioid misuse, and marijuana misuse than their cisgender, heterosexual peers. These findings highlight the need to consider tailored programming for SGM AI/AN/NH students in substance use prevention and intervention efforts in U.S. college settings.

Factors Associated with Non-Binary Gender Identity in Psychiatric Inpatients with Suicidal Ideation Assigned Female at Birth: A Case-Control Study

The study aimed to investigate factors associated with non-binary gender identity in Russian female psychiatric inpatients with suicidal ideation. This case-control study included 38 female inpatients with non-binary gender identity and a control group-76 cisgender women matched for age (age range 19-35 years, M age, 21.5 years); both groups were psychiatric inpatients with suicidal thoughts. All patients underwent the Self-Injurious Thoughts and Behaviors Interview and completed the brief Reasons for Living Inventory. We also used the WHO Quality of Life Questionnaire (WHOQOL-100) and the Life Style Index (LSI). Non-binary gender identity in inpatients with suicidal ideation was associated with lower educational level, higher unemployment rate, being more socially reticent in preschool, and lifetime sexual experience with both male and female partners. In addition, they were younger at the time of the first suicidal ideation, suicide plan development, and attempt. Non-binary inpatients had lower scores in freedom, physical safety, and security facets of WHOQOL-100 and a higher level of intellectualization on LSI. People with non-binary gender identity face educational, employment, and communication issues. They also have distinct suicidal thoughts and behavioral profiles. These issues and differences mean unique approaches to suicide prevention for a population of inpatients with non-binary gender identity are needed.

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.

Experiences with Menses in Transgender and Gender Nonbinary Adolescents

STUDY OBJECTIVE

To describe menstrual history, associated dysphoria, and desire for menstrual management in transgender male and gender diverse adolescents who were assigned female at birth DESIGN: Retrospective chart review SETTING: Tertiary care children's hospital PARTICIPANTS: All patients seen in a multidisciplinary pediatric gender program from March 2015 through December 2020 who were assigned female at birth, identified as transgender male or gender nonbinary, and had achieved menarche INTERVENTION: None MAIN OUTCOME MEASURES: Patient demographics, menstrual history, interest in and prior experiences with menstrual management, parental support, and concerns about menstrual management RESULTS: Of the 129 included patients, 116 (90%) identified as transgender male and 13 (10%) as gender nonbinary, with an average age of 15 (SD 1.6) years. Almost all (93%) patients reported menstrual-related dysphoria. Most (88%) were interested in menstrual suppression. The most common reasons for desiring suppression were achievement of amenorrhea (97%) and improvement of menstrual-related dysphoria (63%).

CONCLUSIONS

Most gender diverse patients assigned female at birth reported dysphoria associated with menses and desired menstrual suppression. This information can encourage physicians to raise this topic and offer menstrual management for gender diverse patients who experience distress related to menses, especially for those who are not ready for or do not desire gender-affirming hormonal treatment. Future research is needed to better understand patients' experiences with menses and to determine the optimal menstrual management methods. This could be an important intervention to improve outcomes for this vulnerable population.

Parental Support, Depressive Symptoms, and LGBTQ Adolescents: Main and Moderation Effects in a Diverse Sample

OBJECTIVE

Research has documented the importance of parental support as a protective factor against depressive symptoms among lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth. In this study, we assessed the relations between LGBTQ-specific parental support and depressive symptoms.

METHOD

Participants were 6,837 LGBTQ youth (ages 13-17) with diverse racial and ethnic, gender, and sexual identities. Main effect and moderation analyses examined interactions between LGBTQ-specific parental support with demographic variables on depressive symptoms, considering demographics as moderators.

RESULTS

We found that participants of color reported less LGBTQ-specific parental support than their White counterparts, that transgender and genderqueer participants reported less LGBTQ-specific parental support than their cisgender counterparts, and that non-monosexual participants reported less LGBTQ-specific parental support than their monosexual counterparts. Disparities in depressive symptoms were found for individuals who identified as Native American and Latinx, non-monosexual, and transgender and genderqueer, such that these groups reported higher levels of depressive symptoms. Further, we found a significant interaction between LGBTQ-specific parental support and ethnicity, with LGBTQ-specific parental support being less strongly associated with participants who identified as Latinx compared to those who did not identify as Latinx. We also found a significant interaction between LGBTQ-specific parental support and gender identity, with LGBTQ-specific parental support being more strongly related to depressive symptoms among participants who did not identify as boys compared to cisgender boys .

DISCUSSION

We discuss how to assess the impact of interlocking systems of oppression when working with LGBTQ youth and their parental figures.

Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people

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.

Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy

BACKGROUND

Recently, the variability and heterogeneity of gender presentations in transgender youths have gained significant attention worldwide. Alongside this, specialized gender services have reported an increase in referrals of youths reporting non-binary identities. In Italy, studies investigating gender identity and expression in gender non-conforming youths are lacking, as are data regarding the non-binary population.

AIM

The present study aimed at dimensionally exploring how transgender and non-binary Italian adolescents identify and express their gender.

OUTCOMES

Gender expression in trans binary youths and non-binary youths.

METHODS

The Gender Diversity Questionnaire (GDQ; Twist & de Graaf, 2019) was used to investigate gender identity, gender fluidity, and gender expression in a sample of 125 adolescent patients from the Gender Identity Development Service (SAIFIP) in Rome and the Gender Incongruence Unit of the Careggi Hospital in Florence, between April 2019-June 2021.

RESULTS

The majority of participants (74.4%) identified as trans* binary and the remaining (25.6%) participants identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity across time and contexts. Almost all participants rated external appearance as important to their gender expression, yet trans binary participants attributed more importance to the body in this respect. Body discomfort and pubertal stage emerged as the most influential factors in participants' experiences of gender. Participants who were assigned male at birth expressed significantly more desire for puberty blockers, whereas those who were assigned female at birth had a stronger desire to engage in breast/chest surgery. Non-binary participants sought different medical interventions relative to trans binary participants.

CLINICAL IMPLICATIONS

These results may be useful for clinicians working with transgender youths as they provide awareness regarding the features of young people who identify within and outside of binary constructions of gender.

STRENGTHS & LIMITATIONS

This study provides useful data in gaining insight into understanding the variety of experiences and challenges of gender non-conforming youths. However as the sample was recruited from specialized services, it may not represent the entire gender non-conforming population in Italy.

CONCLUSION

The results describe the range of gender identities and expressions among gender non-conforming youths attending gender specialized services in Italy, thereby improving our understanding of the variety of identities experienced and the specific medical needs of both trans binary and non-binary adolescents. Mirabella M, Piras I, Fortunato A, et al. Gender Identity and Non-Binary Presentations in Adolescents Attending Two Specialized Services in Italy. J Sex Med 2022;19:1035-1048.

Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19

Academic stress may be the single most dominant stress factor that affects the mental well-being of college students. Some groups of students may experience more stress than others, and the coronavirus disease 19 (COVID-19) pandemic could further complicate the stress response. We surveyed 843 college students and evaluated whether academic stress levels affected their mental health, and if so, whether there were specific vulnerable groups by gender, race/ethnicity, year of study, and reaction to the pandemic. Using a combination of scores from the Perception of Academic Stress Scale (PAS) and the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), we found a significant correlation between worse academic stress and poor mental well-being in all the students, who also reported an exacerbation of stress in response to the pandemic. In addition, SWEMWBS scores revealed the lowest mental health and highest academic stress in non-binary individuals, and the opposite trend was observed for both the measures in men. Furthermore, women and non-binary students reported higher academic stress than men, as indicated by PAS scores. The same pattern held as a reaction to COVID-19-related stress. PAS scores and responses to the pandemic varied by the year of study, but no obvious patterns emerged. These results indicate that academic stress in college is significantly correlated to psychological well-being in the students who responded to this survey. In addition, some groups of college students are more affected by stress than others, and additional resources and support should be provided to them.

Mental health in transgender individuals: a systematic review

Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.

Suicidality in clinic-referred transgender adolescents

Gender and sexually diverse adolescents have been reported to be at an elevated risk for suicidal thoughts and behaviors. For transgender adolescents, there has been variation in source of ascertainment and how suicidality was measured, including the time-frame (e.g., past 6 months, lifetime). In studies of clinic-referred samples of transgender adolescents, none utilized any type of comparison or control group. The present study examined suicidality in transgender adolescents (M age, 15.99 years) seen at specialty clinics in Toronto, Canada, Amsterdam, the Netherlands, and London, UK (total N = 2771). Suicidality was measured using two items from the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). The CBCL/YSR referred and non-referred standardization samples from both the U.S. and the Netherlands were used for comparative purposes. Multiple linear regression analyses showed that there was significant between-clinic variation in suicidality on both the CBCL and the YSR; in addition, suicidality was consistently higher among birth-assigned females and strongly associated with degree of general behavioral and emotional problems. Compared to the U.S. and Dutch CBCL/YSR standardization samples, the relative risk of suicidality was somewhat higher than referred adolescents but substantially higher than non-referred adolescents. The results were discussed in relation to both gender identity specific and more general risk factors for suicidality.

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.

Psychological Wellbeing and Perceived Social Acceptance in Gender Diverse Individuals

BACKGROUND

Over the last few years, the gender binary has been questioned, highlighting the existence of gender diverse people, who identify as neither (exclusively) male nor female.

AIM

The present study evaluated the possible differences in terms of psychological wellbeing between binary and gender diverse individuals, as well as the role of perceived social acceptance and religious fundamentalism as possible mediators of psychopathology in gender diverse people. Furthermore, the diversity of gender-affirming hormonal treatment requests according to gender identification was investigated.

METHODS

A sample of 563 transgender people aged 18-70 was enrolled (n = 264 assigned female at birth, AFAB and n = 299 assigned male at birth, AMAB), all individuals referring to several Italian gender clinics. A subdivision of the study population based on the gender identity visual analog scale (GI-VAS) median was performed, in order to distinguish between gender diverse and binary transgender individuals. Moreover, a linear regression analysis was performed entering logarithmically transformed GI-VAS (Log GI-VAS) into the models with psychometric scales.

OUTCOMES

Psychometric and sociodemographic data, as well as information regarding requests for gender-affirming treatments, were extrapolated from the clinical interviews conducted during the first referral.

RESULTS

Gender diverse individuals showed significantly less intense gender dysphoria and higher levels of depression and anxiety compared to binary ones; accordingly, a less binary gender identity correlated with higher levels of depression and anxiety and lower levels of gender dysphoria. The depressive symptomatology in gender diverse people was partially mediated by perceived discrimination and humiliation. Moreover, gender diverse AMAB people sought a non-standard hormonal treatment more often than their binary counterpart.

CLINICAL IMPLICATIONS

The present study highlights the importance for transgender health professionals, when planning gender-affirming hormonal treatments, to offer flexible interventions, tailored on the patient's needs and goals.

STRENGTHS & LIMITATIONS

Strengths included exploring whether and how perceived discrimination may affect mental health in gender diverse people. Limitations included the enrolled sample of people referring to different gender clinics, which is not fully representative of the transgender population.

CONCLUSION

This study highlights the importance of evaluating each individual's unique health care needs, exploring each single request and its underlying reasons. Romani A., Mazzoli F., Ristori J., et al. Psychological Wellbeing and Perceived Social Acceptance in Gender Diverse Individuals. J Sex Med 2021;18:1933-1944.

Mental and sexual well-being in non-binary and genderqueer individuals

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.

[Assessment and operationalization of the characteristic "gender" in representative population-based surveys: challenges and implications with the example of the GeSiD study]

Repräsentative quantitative Surveys erheben das Geschlecht der Teilnehmenden, um geschlechtsspezifische Analysen im Hinblick auf die jeweiligen Fragestellungen zuzulassen und Rückschlüsse auf die Populationen zu ziehen. Dies ist wichtig, um zielgruppenspezifische Informationen und Angebote zu entwickeln. Doch obwohl Geschlecht nicht mehr ausschließlich als ein binäres Konstrukt betrachtet wird, wird es noch oft durch eine binäre Variable mit den Antwortmöglichkeiten Frau/Mann oder weiblich/männlich erhoben. In diesem Artikel erörtern wir, warum dieses Vorgehen veraltet bzw. unvollständig und eine Abkehr von diesem Ansatz wichtig und notwendig ist. Anhand der GeSiD-Studie zu „Gesundheit und Sexualität in Deutschland“ zeigen wir in diesem Diskussionsbeitrag exemplarisch auf, wie Geschlecht anhand eines zweistufigen Modells erhoben werden kann, bei dem im ersten Schritt das bei der Geburt zugewiesene Geschlecht und im zweiten Schritt die subjektive Geschlechtszugehörigkeit abgefragt wird. Gleichzeitig erörtern wir die Herausforderungen, die dieser Ansatz mit sich bringt. Die Erfahrungen aus der GeSiD-Studie setzen wir in einen größeren Kontext und diskutieren die Implikationen und Möglichkeiten zur Operationalisierung von Geschlecht in repräsentativen Befragungen.

Differences in Patient and Parent Informant Reports of Depression and Anxiety Symptoms in a Clinical Sample of Transgender and Gender Diverse Youth

Purpose: We assessed characteristics of patients at a pediatric gender clinic and investigated if reports of mental health concerns provided by transgender and gender diverse (TGD) youth patients differed from reports provided by a parent informant on their behalf. Methods: This cross-sectional study included 259 TGD patients 8 to 22 years of age attending a pediatric gender clinic in the southeast United States from 2015 to 2020. Pearson correlations and paired sample t-tests compared patient-reported mental health concerns at patient intake with those provided by a parent informant. Clinical symptom severity was assessed with standardized T-scores. Level 2 Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress-Depression Scale and Level 2 PROMIS Emotional Distress-Anxiety Scale assessed depression and anxiety symptoms of patients. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure was used with parents. Results: Patients had a mean age of 14.9 at first visit, with most identifying as White (85.5%), non-Hispanic (91.1%), and as a boy or man (63.6%). Half had moderate-to-severe depression (51.2%) or anxiety (47.9%) symptoms. There was a moderate, positive correlation between patient-reported and parent-reported depression symptoms, with no correlation for anxiety symptoms. Informant type differences were statistically significant (patients reporting greater depression and anxiety symptoms). Conclusions: TGD youth patients reported more severe depression and anxiety symptoms compared with parent informants. Despite moderate agreement on depression symptoms, parents did not accurately detect their child's anxiety symptoms. These discrepancies highlight a need for interventions which increase parental recognition of child mental health status.

Psychological Functioning in Non-binary Identifying Adolescents and Adults

Gender diverse individuals who do not conform to society's binary gender expectations are more likely to experience difficulties in acceptance and in recognition of gender, compared to binary-identifying transgender people. This may accentuate the feeling that their gender identity is not socially recognized or validated. This study aimed to investigate psychological functioning among gender diverse adolescents and adults who identify beyond the binary gender spectrum. In both study populations, 589 clinically-referred gender diverse adolescents from the UK (n = 438 birth-assigned females and n = 151 birth-assigned males), and 632 clinically-referred gender diverse adults from the Netherlands (n = 278 birth-assigned females and n = 354birth-assigned males), we found that a higher degree of psychological problems was predicted by identifying more strongly with a non-binary identity. For adolescents, more psychological problems were related to having a non-binary gender identity and being assigned female at birth. In the adult population, experiencing psychological difficulties was also significantly related to having a stronger non-binary identity and having a younger age. Clinicians working with gender diverse people should be aware that applicants for physical interventions might have a broader range of gender identities than a binary transgender one, and that people with a non-binary gender identity may, for various reasons, be particularly vulnerable to psychological difficulties.

Lifetime prevalence of suicidal ideation and suicidal behaviors in gender non-conforming youths: a meta-analysis

Gender identity represents a topic of growing interest in mental health research. People with non-conforming gender identity are prone to suffer from stigmatization and bullying and often present psychiatric issues, which may in turn lead to a high prevalence of suicidal ideation and behaviors. The present meta-analysis aimed to estimate the prevalence of suicidal ideation and suicidal behaviors in gender non-conforming children, adolescents and young adults. A systematic search was performed in Web of Science and PsycINFO from inception to December 2018. We selected cross-sectional and cohort studies including youths (up to 25 years) with a diagnosis confirmed by a clinician according to international classifications, or after a direct interview with a peer. A random-effects meta-analysis was computed for the following outcomes: non-suicidal self-injury (NSSI), suicidal ideation and suicide attempts. Overall, we found a mean prevalence of NSSI of 28.2% (9 studies, 3057 participants, 95% CI 14.8-47.1). A similar prevalence (28%) was found for suicidal ideation (6 studies, 2249 participants, 95% CI 15-46.3), while the prevalence of suicide attempts was 14.8% (5 studies, 1039 participants, 95% CI 7.8-26.3). Subgroup analyses revealed no significant differences according to biological sex. Given the prevalence of suicidal behaviors in gender non-conforming youths, it appears desirable to implement therapeutic and support strategies for this population. Moreover, educational interventions directed to parents, teachers, mental health professionals and general community should be promoted to struggle against stigma and social isolation, factors that may contribute to increasing the risk of suicidal behaviors.

The clinical profile of patients attending a large, Australian pediatric gender service: A 10-year review

Objectives: To better understand the clinical profile of patients attending a large Australian pediatric gender service. Retrospective clinical audit of patients seen at the Royal Children's Hospital Gender Service (RCHGS) over 10 years (2007-16). Setting: The RCHGS: Australia's largest pediatric gender service. Participants: Patients were eligible for inclusion if they had an appointment with the RCHGS between January 2007 - December 2016, and had either a self-reported gender which differed from what was presumed for them at birth or sought guidance regarding gender identity/expression. Main outcome measures: Demographic/developmental history, clinical presentation including information about gender identity/dysphoria, comorbidities, self-harm, suicidal ideation, gender-affirming treatment, psychosocial functioning. Results: 359 patients were first seen during the study period. Assigned females (54%) slightly outnumbered assigned males (46%), and presented at an older age (14.8 vs 12.4 years. Patients predominantly identified as transgender (87.2%) or non-binary (7.2%). Across the cohort, gender diversity was evident from a young age (median age 3), and symptoms of gender dysphoria were noted earlier in assigned males (median age 4) than assigned females (median age 11). Although 81% of patients met eligibility for GD, rates of hormonal treatment were much lower, with 29% of young people ≥10 years of age receiving puberty blocking treatment and 38% of adolescents ≥ 16 years of age receiving gender-affirming hormones (i.e. testosterone or estrogen). Many patients had mental health difficulties and/or neurodevelopment disorders, including major depressive disorder/low mood (51%), self-harm (25%), suicidal ideation (30%) and autism spectrum disorder (16%). Conclusion: This audit illustrates the complex profile and needs of transgender and gender diverse children and adolescents presenting to specialist gender services. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1939221 .

Exploring Health and Transition-Related Needs in Polish Transgender and Non-Binary Individuals

BACKGROUND

Gender diverse individuals constitute a substantial yet still understudied population. Particularly little is known about gender non-binary people whose health needs have only recently gained attention from clinicians.

AIM

To investigate needs for gender-affirming interventions, selected health indicators and determinants in Polish gender non-binary individuals as compared to transgender men and transgender women.

METHODS

We analyzed a subset of data from an online study on health in members of the Polish LGBTQ community. The sample consisted of 53 persons who self-identified as non-binary and 45 transgender men and transgender women. The uptake and the desire for gender-affirming medical interventions as well as selected health indicators were compared in non-binary and transgender persons. Additionally, regression models were conducted for depression, self-esteem and somatic symptoms severity as dependent variables, age as a covariate, and perceived stigma exposure, resilience and discomfort associated with current gender expression as predictors.

OUTCOMES

Outcomes such as desire for gender-affirming medical interventions and legal gender reassignment, symptoms of depression, resilience, physical symptoms severity, and perceived stigma exposure were captured in self-reported questionnaires.

RESULTS

Compared to the transgender men and transgender women, the non-binary participants of the study significantly less often pursued or desired gender-affirming medical interventions and legal gender reassignment. The non-binary participants also felt significantly more discomfort with their current gender expression. They were also characterized by increased expectations of rejection, vicarious trauma associated with being an LGBTQ person, and by decreased resilience compared to the transgender men and transgender women. Non-binary identity and individual resilience predicted higher self-esteem and decreased depression in the sample. The severity of physical symptoms was predicted by perceived stigma exposure (positively) and by resilience (negatively).

CLINICAL IMPLICATIONS

Polish non-binary individuals may constitute a vulnerable population in terms of greater perceived exposure to stigma and decreased individual resilience. Both transgender and non-binary individuals seek gender-affirming interventions and legal gender reassignment; the latter group, however, does so significantly less often.

STRENGTHS & LIMITATIONS

We analyzed the data from a unique and understudied Polish population. By exploring the diversity within the transgender and non-binary community, we add to the ongoing discussion on transgender and non-binary health. The major limitations of the study are convenience sampling, cross-sectional design, and limited sample size.

CONCLUSION

Non-binary individuals constitute a distinct population in terms of psychosocial and health-related characteristics. Clinicians should be aware of their needs and the challenges they face in association with living in a predominantly gender binary-oriented society. Koziara K, Mijas M. Wycisk J, et al. Exploring Health and Transition-Related Needs in Polish Transgender and Non-Binary Individuals. J Sex Med 2021;18:1110-1121.

Understanding the Impact of the COVID-19 Pandemic on the Mental Health of Transgender and Gender Nonbinary Individuals Engaged in a Longitudinal Cohort Study

While the COVID-19 pandemic in the United States disproportionately impacts marginalized communities, no empiric US-based research has focused specifically on transgender and gender nonbinary (TGNB) people. We examined the pandemic's impact on an established longitudinal cohort of TGNB individuals (N = 208) by administering an online survey between March-June 2020. We used multivariable linear regression to examine reduced LGBTQ/TGNB community support and disruptions in gender-affirming health care as predictors of psychological distress during the pandemic. We found that the pandemic exacerbated ongoing mental health disparities for TGNB individuals. Furthermore, reduced LGBTQ/TGNB support was associated with increased psychological distress during the pandemic. Interruption and/or delay in gender-affirming health care was not associated with increased psychological distress during the pandemic. Special attention is needed to address the unique ways in which TGNB individuals were affected by the COVID-19 pandemic. This includes increasing access to LGBTQ/TGNB community support and addressing long-standing health disparities.

Descriptive Study of Transgender Youth Receiving Health Care in the Gender Identity Program in Southern Brazil

Since 2014, the Gender Identity Program (PROTIG) of Hospital de Clínicas de Porto Alegre (HCPA) has been assisting transgender youth seeking gender-affirmative treatment offered at a public health-care service specializing in gender in southern Brazil. This article aims to analyze sociodemographic and clinical data regarding the diagnoses of gender dysphoria and gender incongruence, psychiatric comorbidities, and clinical aspects of a sample of transgender youths seeking health care in the gender identity program. The research protocol consisted of a survey of the data collected in the global psychological evaluation performed at the health-care service for youths diagnosed with gender incongruence and their caretakers. Participating in this research were 24 transgender youths between 8 and 16 years old with diagnostic overlap of gender dysphoria [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)] and gender incongruence [International Classification of Diseases, 11th Revision (ICD-11)] and 34 of their caregivers. Of the young people, 45.8% were positive for some psychiatric comorbidity throughout their lives, with almost half (45.4%) having two or more psychiatric comorbidities in addition to gender dysphoria. The mental health professionals comprising affirmation care teams face the challenge of adapting the care protocols to the uniqueness of each demand by developing individualized forms to promote healthy development. This can be done by focusing not only on medical and physical interventions for gender affirmation but also on the promotion of mental health and general emotional well-being. Thus, the gender affirmation model, which advocates for global assessment and personalized guidance, proved to be adequate. Nevertheless, access to multidisciplinary health services specializing in gender is essential for promoting the general well-being of the population of transgender youth.