Presentation of gender dysphoria: A perspective from Eastern India

A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment

It is unclear whether the literature on adolescent gender dysphoria (GD) provides evidence to inform clinical decision making adequately. In the final of a series of three papers, we sought to review published evidence systematically regarding the types of treatment being implemented among adolescents with GD, the age when different treatment types are instigated, and any outcomes measured within adolescence. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none at that time), we searched Ovid Medline 1946 -October week 4 2020, Embase 1947-present (updated daily), CINAHL 1983-2020, and PsycInfo 1914-2020. The final search was carried out on 2nd November 2020 using a core strategy including search terms for 'adolescence' and 'gender dysphoria' which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 19 papers from 6 countries representing between 835 and 1354 participants were included in our final sample. All studies were observational cohort studies, usually using retrospective record review (14); all were published in the previous 11 years (median 2018). There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 71% to 95%, with a mean of 82%. Puberty suppression (PS) was generally induced with Gonadotropin Releasing Hormone analogues (GnRHa), and at a pooled mean age of 14.5 (±1.0) years. Cross Sex Hormone (CSH) therapy was initiated at a pooled mean of 16.2 (±1.0) years. Twenty-five participants from 2 samples were reported to have received surgical intervention (24 mastectomy, one vaginoplasty). Most changes to health parameters were inconclusive, except an observed decrease in bone density z-scores with puberty suppression, which then increased with hormone treatment. There may also be a risk for increased obesity. Some improvements were observed in global functioning and depressive symptoms once treatment was started. The most common side effects observed were acne, fatigue, changes in appetite, headaches, and mood swings. Adolescents presenting for GD intervention were usually offered puberty suppression or cross-sex hormones, but rarely surgical intervention. Reporting centres broadly followed established international guidance regarding age of treatment and treatments used. The evidence base for the outcomes of gender dysphoria treatment in adolescents is lacking. It is impossible from the included data to draw definitive conclusions regarding the safety of treatment. There remain areas of concern, particularly changes to bone density caused by puberty suppression, which may not be fully resolved with hormone treatment.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Affirmation as Male

Gender-affirming hormone therapy (GAHT) is the most frequent treatment offered to gender-incongruent individuals, which reduces dysphoria. The goal of therapy among gender-incongruent individuals seeking gender affirmation as male is to change their secondary sex characteristics to affect masculine physical appearances. GAHT greatly improves mental health and quality of life among gender incongruent individuals. India-specific guideline for appropriate care for gender-incongruent individuals is almost absent. This document is intended to assist endocrinologists and other healthcare professionals interested in gender incongruity for individuals seeking gender affirmation as male. A safe and effective GAHT regimen aims to effect masculinising physical features without adverse effects. In this document, we offer suggestions based on an in-depth review of national and international guidelines, recently available evidence and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement provides protocols for the hormone prescribing physicians relating to diagnosis, baseline evaluation and counselling, prescription planning for masculinising hormone therapy, choice of therapy, targets for monitoring masculinising hormone therapy, clinical and biochemical monitoring, recommending sex affirmation surgery and peri-operative hormone therapy. The recommendations made in this document are not rigid guidelines, and the hormone-prescribing physicians are encouraged to modify the suggested protocol to address emerging issues.

Endocrine Therapy of Adult Gender-Incongruent Individuals Seeking Gender Reaffirmation

Gender-affirming hormone therapy (GAHT) is integral to the management of gender-incongruent (GI) individuals. GAHT greatly improves the quality of life for GI individuals. Current research about outcomes of GAHT and adverse events in adults receiving GAHT is limited in India and large cohort studies are absent. This document on medical management provides protocols for the prescribing clinician relating to counseling for GAHT, baseline evaluation, choice of therapy, targets for hormone therapy, clinical and biochemical monitoring, and perioperative hormone therapy.

A PRISMA systematic review of adolescent gender dysphoria literature: 2) mental health

It is unclear whether the literature on adolescent gender dysphoria (GD) provides sufficient evidence to inform clinical decision making adequately. In the second of a series of three papers, we sought to review published evidence systematically regarding the extent and nature of mental health problems recorded in adolescents presenting for clinical intervention for GD. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none), we searched Ovid Medline 1946 -October week 4 2020, Embase 1947-present (updated daily), CINAHL 1983-2020, and PsycInfo 1914-2020. The final search was carried out on the 2nd November 2020 using a core strategy including search terms for 'adolescence' and 'gender dysphoria' which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 32 papers from 11 countries representing between 3000 and 4000 participants were included in our final sample. Most studies were observational cohort studies, usually using retrospective record review (21). A few compared cohorts to normative or population datasets; most (27) were published in the past 5 years. There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 45% to 96%, with a mean of 81%. More than a third of the included studies emerged from two treatment centres: there was considerable sample overlap and it is unclear how representative these are of the adolescent GD community more broadly. Adolescents presenting for GD intervention experience a high rate of mental health problems, but study findings were diverse. Researchers and clinicians need to work together to improve the quality of assessment and research, not least in making studies more inclusive and ensuring long-term follow-up regardless of treatment uptake. Whole population studies using administrative datasets reporting on GD / gender non-conformity may be necessary, along with inter-disciplinary research evaluating the lived experience of adolescents with GD.

Exploring Cross-Sectional Predictors of Suicide Ideation, Attempt, and Risk in Gender Incongruent Adults in India

INTRODUCTION

Suicide rates and suicidal tendencies among gender incongruent persons are higher compared to the general population. Yet little is known about the factors that are relevant for suicide-related outcomes among Indian gender incongruent individuals.

MATERIALS AND METHODS

Within a large sample of gender incongruent adults (n=120), we examined the contribution of demographic (age, assigned sex, gender identity, relationship, and addiction status) and socio-economic variables (education, profession, income, social support) in the prediction of three suicide-related outcomes: past-year suicidal thought, history of suicidal attempt and a composite measure of the two.

RESULTS

Of the entire sample, 25.8% (n=31) reported a past suicide attempt, with 18.3% (n = 22) reporting one attempt, 2.5% (n = 3) reporting two attempts, 1.7% (n = 2) reporting three attempts and 2.5% (n=3) reporting four to six attempts. The age at which the first suicide attempt occurs is mostly between 16 to 18 years. 19.26% (n = 21) reported that although they had not attempted suicide, they had given serious thought to killing themselves in the last year. A Chi-square test was conducted to ascertain each demographic variable and socio-economic marker. However, none of these proposed predictors correlated with suicide-related outcomes in our cohort.

CONCLUSIONS

The gender incongruent community is highly susceptible to suicidal behavior. Gender identity may be the risk factor for that behavior. Further study with larger population needs to identify other relevant risk factors, including gender-related victimization and mental health conditions as risk factors.

Lives of Gender Incongruent Community: An Indian Subset Chants "All is Well"

CONTEXT

Gender incongruent individuals are exposed to unique stressors as a result of their minority social position. Poor social support has a further adverse impact on the lives and wellbeing of gender incongruent individuals. There is a paucity of scientific data from India on the socioeconomic status (SES) of gender incongruent community.

AIMS

Aim of the study is to understand and estimate the social support, wellbeing, and SES of gender incongruent individuals in Eastern India.

SUBJECTS AND METHODS

Data of 120 gender incongruent patients from the endocrinology outpatient department of a tertiary care hospital in eastern India were collected. We looked at demographic characteristics, social support, underlying psychiatric comorbidities, and SES. SES was calculated by the Kuppuswamy's socioeconomic status (KSS) scale based on occupation, education, and income.

STATISTICAL ANALYSIS USED

Microsoft Word and Excel were used to generate tables.

RESULTS

Most of the gender incongruent individuals were transfeminine. Almost half of them had no history of addiction. Most of them had good support from family and friends and very few (only 3%) had mental health problems. Calculation by KSS scale showed most of the study population lay in the upper middle or lower middle socioeconomic class.

CONCLUSIONS

Strong support from friends and family appears a key factor for protection against psychiatric comorbidities and an all-round impact on the lives and wellbeing of the study population.

Health of transgender men in low-income and middle-income countries: a scoping review

INTRODUCTION

Despite the rapid growth of research on transgender (trans) health globally, the extent of research on trans men and other transmasculine persons assigned the female sex at birth remains unclear. We, therefore, conducted a scoping review on trans men's health in low-income and middle-income countries (LMICs).

METHODS

The review included peer-reviewed articles and conference abstracts, and grey literature published from 1 January 1999 to 5 July 2019 in English, French, Hindi or Spanish and reporting original quantitative and/or qualitative data on the health of trans men or transmasculine persons living in LMIC. Studies were excluded if they did not disaggregate data for trans men or if they only described surgical techniques or laboratory values.

RESULTS

We included 53 studies (42 peer-reviewed and 11 grey literature) from 19 LMIC. Most were conducted in higher-middle-income countries (n=12) and in Latin America (n=16, 30.2%), the Middle East (n=14, 26.4%) or Sub-Saharan Africa (n=12, 22.6%) and published in 2014 or later (n=44, 83.0%). Approximately half of studies used quantitative methods (52.8%, n=28), of which 64.3% (n=18) had fewer than 50 participants and 14.2% (n=4) had over 150. Across study designs, social determinants of health and gender-affirming care were the most commonly represented domains (49.1% and 47.1% of studies respectively), with common themes including gender-based violence, coercion and discrimination as well as unprescribed hormone use. Other domains represented included mental health (32.1%), sexual and reproductive health (24.5%), general healthcare access (18.9%), physical health (9.4%) and substance use (9.4%).

CONCLUSION

Greater inclusion and disaggregation of trans men and transmasculine persons in global health research is needed to support sex- and gender-based analyses of trans health. Community-based research approaches and theoretically driven research may help to increase the relevance and rigour of such research. Funders should invest in research on trans men's health in LMIC.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Reaffirmation as Female

Cross sex hormone therapy (CSHT) is a strongly desired medical intervention for gender incongruent individuals. The goal is to change secondary sex characteristics to facilitate gender presentation that is consistent with the desired sex. When appropriately prescribed CSHT can greatly improve mental health and quality of life for gender incongruent individuals. Appropriate care for gender incongruent individuals in India is almost absent due to lack of country specific guideline and lack of training amongst the medical professionals. This document is intended to assist endocrinologists and physicians whose adult gender incongruent client is seeking gender reaffirmation as female (transfeminine). These individuals require a safe and effective CSHT regimen that will suppress endogenous male hormone secretion and maintain physiologic levels of female sex hormone. In this document, we offer suggestions based on an in-depth review of Guidelines of Endocrine Society, The World Professional Association for Transgender Health guidelines, the Sappho Good Practice Guide of India and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel are not gender specialists by training but have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement on medical management provides protocols for the prescribing clinician relating to diagnosis, baseline evaluation and counselling, prescription planning for feminizing hormone therapy and anti-androgen therapy, targets for monitoring hormone therapy, choice of therapy, clinical and biochemical monitoring, recommending sex reaffirmation surgery and peri-operative hormone therapy. The recommendations made in this document should not be perceived as a rigid set of guidelines and the treating clinicians are encouraged to modify our suggested protocols to address emerging issues.

Thinking about ethnicity and gender diversity in children and young people

BACKGROUND

Little is known about how social and cultural variants interact with gender identity development. This article aims to identify the ethnicities of children and young people referred to the United Kingdom's national Gender Identity Development Service (GIDS), and compare the ethnicity data with the UK child population and referrals to Child and Adolescent Mental Health Services (CAMHS).

METHODS

GIDS referrals made between April 2012 and April 2015 for children and young people were retrieved. Ethnicity data were obtained by the '16 + 1' ethnicity list. Chi-square and t-tests were performed on the demographics.

RESULTS

Less than 10% of the 995 referrals at GIDS were from Black and minority ethnic (BME) groups - an underrepresentation as compared with both the national population and CAMHS figures. No significant differences in ethnic representation were found between the demographic birth-assigned sexes, across age groups, or year of referral.

CONCLUSIONS

Hypotheses proposed for this underrepresentation take into account both the potential barriers to accessing services and the possibility of cross-cultural variations in the conceptualisations of gender, gender roles and gender diversity. Ethnicity, culture and religion, and their overlapping relationship with gender need further exploration.