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Non-suicidal self-injury and suicidality in trans people: A systematic review of the literature

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ABSTRACT: Literature has described high levels of mental health problems among trans people, such as depression, resulting in increased levels of non-suicidal self-injury (NSSI) behaviour and suicidality (suicidal thoughts, suicide attempts and suicide rates). With the aim of systematically reviewing the available literature in this field, this study identifies thirty-one papers that explore the rates of NSSI and suicidality in trans people. From reviewing the literature, it was revealed that trans people have a higher prevalence of NSSI and suicidality compared to the cisgender (non-trans) population. There appear to be some gender differences within these rates, with trans men at a greater risk for NSSI behaviour. Prevalence rates differ depending on the different stages of transition, but they are still overall greater than the cisgender population. The study concludes that trans individuals are at a greater risk of NSSI behaviour and suicidality than the cisgender population, and discusses risk factors and the need to develop effective preventative interventions.

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... This can include those who conform to the notion of a gender binary and wish to transition from one gender to another, or those who reject this idea (e.g., genderqueer, nonbinary, etc.). Some transgender people can experience discomfort or distress relating to the discrepancy between their gender identity and that which they were assigned at birth ( Marshall et al., 2016), this is referred to as gender dysphoria. ...
... That the majority of research is clinic-based excludes those who do not wish for the support of specialist clinics, those who do not have the support around them to attend, or those who cannot afford to access these services in countries where health care is not covered (Connolly et al., 2016). These findings therefore cannot be generalized to transgender people who have never attended a specialist clinic (Marshall et al., 2016). Previous research is also limited as it often does not include those who do not identify male, female or transgender, e.g. ...
... It is hard to draw conclusions from some of the literature in this area because a distinction is generally not made between nonsuicidal selfharm and suicide attempts (e.g., Aitken et al., 2016). Marshall et al. (2016) call for more research accessing nonclinic participants to capture the variations in of the transgender population. This study therefore focused on a nonclinical sample of self-identified trans and cisgendered adolescents, with the aim of investigating their experiences of low mood, bullying, associated support, peer-related self-harm and selfharm ideation. ...
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Background: Trans youth have been reported to have high rates of self-harm, depression and bullying, and find it difficult to seek support. However, much of this research comes from gender identity clinics; non-clinical samples and those who reject gender binaries remain under-researched. Aims: This study investigated the experiences of a community school-based sample of Trans, identifying youth, Other, and cis-gendered adolescents in relation to their experiences of low mood, bullying, associated support, self-harm ideation and peer-related self-harm. Methods: An online survey was completed by 8440 13–17 year olds (3625 male, 4361 female, 227 Other, and 55 Trans). Results: Trans and Other students had significantly higher rates of self-harm ideation and peer self-harm, in comparison to cis-gendered students. These Trans and Other students reported significantly higher rates of bullying and self-reported depression and significantly less support from teachers and staff at school, in fact these students did not know where to go to access help. Discussion: This community sample confirms findings of high rates of self-harm ideation, self-reported depression and bullying for Trans youth as previously reported in clinic-based samples. However, by accessing a community sample, the salience of the category “Other” was established for young people today. While Other and Trans identified students both struggled to find support, those who identified as Trans were more likely to have been bullied, and have experienced self-reported depression and thoughts of self-harm. Thus, those who identify as transgender represent a high-risk group that needs targeted support within schools and by statutory and nonstatutory community services. Unpacking the category of Other would be beneficial for future research, as well as exploring resilience within this group and intersecting identities such as sexuality, Autism, or experiences such as earlier abuse.
... Systematic reviews regarding suicide risk among transgender people thus far have primarily focused on prevalence rates, and none have reviewed correlates of suicide ideation and attempts separately. These reviews have revealed prevalence rates of suicide ideation and attempts that are alarmingly higher than the general population (Adams et al., 2017;Marshall et al., 2015;McNeil et al., 2017). Among transgender individuals, 55% and 29% engage in suicide ideation and attempts in their lifetime, respectively (Adams et al., 2017), which exceeds general population rates (9.2% and 2.7%, respectively; Nock et al., 2008). ...
... Data regarding suicide deaths among transgender people are scarce; however, transgender individuals undergoing gender affirmation surgery were 19 times more likely to die by suicide compared to the general population in Sweden (Dhejne et al., 2011). One caveat regarding these data is that prevalence rates of suicide ideation and attempts among transgender people may be high due to the frequent use of clinical samples (Marshall et al., 2015). However, prevalence rates of suicide ideation and attempts among transgender people are comparable to samples of individuals with major depressive disorder, a strong risk factor for suicide (Brown, Beck, Steer, & Grisham, 2000). ...
... Systematic reviews have examined correlates within lesbian, gay, bisexual, and transgender people (e.g., King et al., 2008;Matarazzo et al., 2014); however, these reviews do not evaluate correlates that may be unique to transgender individuals' experiences. Three systematic reviews have focused on suicide ideation and behavior solely among transgender people; however, only two of these reviews have explored correlates of such thoughts and behavior, with none reviewing separately correlates of thoughts and behaviors (Marshall et al., 2015;McNeil et al., 2017). Marshall et al. (2015) systematically reviewed the literature from January 1966 to April 2015 on prevalence rates of suicide ideation, attempts, and deaths among transgender people. ...
Article
Transgender people are at high risk for suicide ideation, attempts, and deaths compared to the general population. Several correlates of suicide ideation and attempts have been identified empirically to understand this increased risk. However, few attempts have been made to systematically review this literature. Further, a theory to understand and identify targetable factors for intervention has rarely been applied to this population. In the first systematic review guided by ideation-to-action frameworks of suicide, we systematically reviewed the literature from January 1991 to July 2017 regarding correlates of suicide ideation, attempts, and deaths among transgender people. To be included in the review, articles must have been reported in English, reported on empirical data, included a sample or subsample of transgender people, and reported separately on correlates of suicide ideation, attempts, or deaths. Two independent reviewers searched three major databases, references of included articles, and unpublished literature, which produced 45 articles for review. The review suggested that ideation-to-action frameworks would be worth investigating within this population, with attention to sources of psychological pain, social connectedness, and capacity/capability for suicide unique to this population. Additionally, other aspects of cultural identity were often studied (e.g., race, religion), suggesting the need to understand intersectionality of identities among transgender people and their effects on suicide risk. Finally, the review highlighted important limitations of the literature, namely measurement of suicide ideation and attempts and sampling method, which future work should seek to improve.
... Quantitative meta-analytic methods in transgender health research have been employed to determine the psychological effects of gender transition through hormone therapy (Hughto et al., 2016) and gender-confirming surgery (Murad et al. 2010), and to identify the rates at which trans people experience negative health outcomes, such as suicidality (Marshall et al., 2016) and HIV infection (Baral et al., 2013). In addition, nationwide surveys were administered in the United States in 2008 (Grant et al., 2011) and 2015 (James et al., 2016) reporting the rates at which trans people experience discrimination, violence, and abuse in daily life. ...
... With this framing, these research findings become unsurprising. Why should we expect negative health outcomes among trans people—which are related to stigma, lack of social support, and discrimination (Bockting et al., 2013, Marshall et al., 2016)—to abate post-surgery, when the underlying social problems have not been addressed?Baral (2013)conducted a systematic review and meta-analysis of global HIV infection rates among trans women. The pooled prevalence rate, with data contributed from 15 countries and 11,066 participants, was 19.1%. ...
... Just as social epidemiologists have shifted to a structural analysis of health inequities, so too must technology developers and researchers. In doing so, we can move toward personal health informatics as a " science of change " that recognizes the field's relationship with, and impact on, social life.Create online tools and resources for providers; record and distribute accounts of negative health care experiences; address economic inequality that leads to inaccessible health care; enable health care advocates to combat denial of services; improve research on health care facilitatorsMarshall et al. 2016Systematic review of quantitative studies on nonsuicidal self-injury and suicidality among trans people 31 ...
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... for suicide attempts (n = 29) (Olson, Schrager, Belzer, Simons, & Clark, 2015). Comparable figures have been reported for adults with gender dysphoria (for review, see Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016; Zucker, Lawrence, & Kreukels, 2016). The purpose of the present study was to identify the extent of psychosocial and psychological vulnerability in a clinic-referred population of adolescents diagnosed with gender dysphoria. ...
... for suicide attempts (n = 29) (Olson, Schrager, Belzer, Simons, & Clark, 2015). Comparable figures have been reported for adults with gender dysphoria (for review, see Marshall, Claes,Bouman, Witcomb, & Arcelus, 2016;Zucker, Lawrence, & Kreukels, 2016). The purpose of the present study was to identify the extent of psychosocial and psychological vulnerability in a clinic-referred population of adolescents diagnosed with gender dysphoria. ...
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For adolescents with gender dysphoria, it has become common to be offered hormonal treatment to either delay or suppress pubertal development and/or to masculinize or feminize the body. At the same time, it has been our clinical impression that the psychological vulnerability of at least some of these youth has been overlooked. Fifty consecutive referrals of adolescents with a DSM-IV-TR diagnosis of Gender Identity Disorder (GID) constituted the sample. Information obtained at intake was coded for the presence or absence of 15 psychosocial and psychological vulnerability factors. The mean number of psychosocial/psychological vulnerability factors coded as present was 5.56 (range, 0-13). Over half of the sample had 6 or more of the vulnerability factors. The number of factors coded as present was significantly correlated with behavioral and emotional problems on the Youth Self-Report form and the Child Behavior Checklist, but not with demographic variables or IQ. The findings supported the clinical impression that a large percentage of adolescents referred for gender dysphoria have a substantial co-occurring history of psychosocial and psychological vulnerability, thus supporting a "proof of principle" for the importance of a comprehensive psychologic/psychiatric assessment that goes beyond an evaluation of gender dysphoria per se.
... Furthermore, transgender individuals report high rates of adverse experiences, including physical and sexual assaults, bullying, harassment, and discrimination (Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016). These adverse experiences can begin at a young age, with individuals being victimized in grade school for perceived differences from their peers (Wyss, 2004). ...
... When interpreting these findings, it is important to consider the external nature of these resilience factors. As demonstrated within the present study as well as previous literature (e.g., Marshall et al., 2016), transgender individuals are at a drastically increased risk of experiencing gender-based discrimination, harassment, and violence. It is possible that accessing these external forms of resilience and engaging with the broader transgender community requires a certain level of disclosure and visibility, which exposes transgender individuals to the potential for additional stress, discrimination, and even violence. ...
Article
Transgender individuals are disproportionately impacted by negative mental and physical health outcomes, including increased suicide risk. The gender minority stress theory proposes a potential pathway to suicide risk through distal and proximal stressors. However, little research has examined how resiliency impacts this relationship. The present study explored the moderating role of resiliency in the relationship between stressors, trauma exposure, and suicide risk. Stressors and trauma exposure were significantly associated with suicide risk, but community resilience was not found to moderate this relationship. The clinical implications of these findings are discussed in depth.
... It is essential to use inclusive measures of gender identity in any quantitative study, to ensure that all participants are able to report their gender (see Fraser, Bulbulia, Greaves, Wilson, & Sibley, 2017 for discussion). This is particularly important in NSSI research, however, as past research shows that transgender and gender nonconforming people are particularly vulnerable to engaging in NSSI (Marshall, Claes, Bouman,Witcomb, & Arcelus, 2016). While we provided participants the option of identifying as transgender, we did not stipulate that participants could check more than one box (e.g., " female " and " transgender " ). ...
... It is essential to use inclusive measures of gender identity in any quantitative study, to ensure that all participants are able to report their gender (see Fraser, Bulbulia, Greaves, Wilson, & Sibley, 2017 for discussion). This is particularly important in NSSI research, however, as past research shows that transgender and gender nonconforming people are particularly vulnerable to engaging in NSSI ( Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016). While we provided participants the option of identifying as transgender, we did not stipulate that participants could check more than one box (e.g., "female" and "transgender"). ...
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Objectives Despite increasing interest in the prevalence and correlates of Non-Suicidal Self-Injury (NSSI) in adolescent populations, relatively few studies have examined NSSI among lesbian, gay and bisexual (LGB) adolescents. The current study explored sexuality concerns and elevated emotion dysregulation as potential mechanisms underlying the relationship between sexual orientation elevated non-suicidal self-injury (NSSI). Methods A community sample of 1799 adolescents completed a questionnaire assessing NSSI, sexual orientation, sexuality concerns, and emotion regulation. Results Across the study, 20.6% of adolescents reported a history of NSSI. Adolescents who identify as 'mostly heterosexual', 'bisexual', and 'mostly homosexual' were more likely to engage in NSSI than gay/lesbian, heterosexual and asexual adolescents. Multiple mediation analysis showed that emotion regulation, but not sexuality concerns, mediated the relationship between sexual orientation and NSSI. Conclusion The current study tested two theoretical pathways by which sexual orientation could predict NSSI engagement. Findings suggest that literature on general psychological processes, as well as group-specific minority stressors, can shed light on high rates of NSSI among LGB populations. Specifically, the challenges faced by LGB adolescents may undermine the development of emotion regulation. As such, this should be a key target of intervention with LGB adolescents engaging in NSSI.
... Psychiatric co-morbidities, specifically depression, must be addressed when treating transgender individuals with epilepsy. Suicide rates are increased in both populations, as high as 12% in those with epilepsy, and in transgender individuals, studies citing up to 45%, compared to 1.1-1.2% in the general population [34,35]. ...
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Purpose of Review The goal of this review is to outline the main considerations when treating transgender patients with epilepsy. Points to be addressed include the gender affirming hormone therapy regimens and how they interact with anti-seizure medications and seizure control, as well as common co-morbidities in the transgender epilepsy population. Recent Findings Gender affirming hormone therapy (GAHT) may affect seizure control directly, due to proconvulsant or anticonvulsant properties. GAHT may interact with anti-seizure medications; most notably, estrogen will decrease serum concentration of lamotrigine. Enzyme-inducing anti-seizure medications may decrease hormone levels, potentially interfering with goals of GAHT. Transgender epilepsy patients are at risk for co-morbidities such as decreased bone mineral density and depression. Summary There are minimal direct studies on treatment or outcomes in the transgender epilepsy population. Providers must be knowledgeable about the bi-directional interactions between gender affirming hormone therapy and anti-seizure medications, as well as direct hormonal influences on seizure control. Future research should directly evaluate outcomes in transgender epilepsy patients with regard to seizure control, success of hormone therapy, and management of co-morbidities, to further educate providers and patients how to best manage their healthcare.
... This could develop into a powerful coping skill that might keep these individuals from resorting to unhealthy behaviours such as self-harming. This is particularly important in this population, as research shows a strong association between being trans and mental health problems, particularly depression and self-harm as a way to manage one's trans feelings (Claes et al., 2015; Davey et al., 2015; Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005; Marshall et al., 2016; Nuttbrock et al., 2010; Operario & Nemoto, 2005). This is not surprising, as the discomfort and distress about assigned gender and body dissatisfaction ( Jones et al., 2016) may lead to a sense of hopelessness, which can bring with it low mood, selfinjury and even suicide (Dhejne et al., 2011). ...
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Video gaming has become an established area of psychological research over the last two decades. Over the past few years there has been increasing research into online gender swapping, showing that for many groups or individuals it can have positive psychological benefits (e.g., as a way to explore gender roles and boundaries in a safe environment). To date, no research has ever examined online gender swapping among individuals with gender dysphoria – people with acknowledged gender-identity issues. Using four case studies, this exploratory study examined the role of gaming in the life of individuals seeking treatment for gender dysphoria. The main objectives were to use exemplar case studies to highlight that gaming – in some circumstances – appears to be a functional way of dealing with gender identity issues, and that gender swapping in gaming may help such individuals to come to terms with their gender dysphoria. Recommendations for further research are suggested along with the limita- tions of the data collected.
... Dhejne et al., 2016). Jedoch verwendeten die wenigsten Studien passende Kontrollgruppen und die meisten der 11 Longitudinalstudien berichteten nach medizinischen geschlechtsangleichenden Maßnahmen eine Verbesserung der psychischen Gesundheit, teilweise vergleichbar mit der Allgemeinbevölkerung. Eine weitere Über-blicksarbeit mit 31 Studien berichtete für trans* Personen klar erhöhte Raten an nicht suizidalen Selbstverletzungen, Suizidversuchen und Suiziden, verglichen mit cisgender Personen oder der Allgemeinbevölkerung (Marshall et al., 2016 ). Das erhöhte Risiko fand sich auch in Longitudinalstudien. Die umfangreichste Studienübersicht zeigt, dass trans* Personen in der Regel höhere Ausprägungen an Suizidgedanken und Suizidversuchen haben, verglichen mit LSB Personen (Ramsay & Tremblay, 2015 ). ...
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Zusammenfassung: Lesbische, schwule, bisexuelle, transgender und intersexuelle (LSBTI) Menschen scheinen ein erhöhtes Risiko für psychische Erkrankungen und Suizidalität zu haben, wie aus vielen internationalen Studien hervorgeht. In diesem Beitrag wird die aktuelle Studienlage dargestellt und auf methodologische Herausforderungen eingegangen. Während für lesbische, schwule und bisexuelle Menschen die Evidenz für das höhere Erkrankungsrisiko robust erscheint, ist die Datenlage zu Transgender und Intersexualität noch eher dürftig, die Ergebnisse sprechen aber auch hier für ein erhöhtes Risiko. Weiters werden in diesem Beitrag neuere wissenschaftlich fundierte Erklärungsmodelle zur psychischen Gesundheit von LSBTI Menschen vorgestellt. Diese haben pathologisierende Ansichten über LSBTI abgelöst und fokussieren auf die Folgen gesellschaftlicher Homo-, Bi-, Trans-und Interphobie. Daraus resultierende verschiedene Formen von Minoritätenstress, welchen LSBTI Menschen oder jene, die als LSBTI wahrgenommen werden, ausgesetzt sind, können das erhöhte Krankheitsrisiko gut erklären. Die Kenntnis des Erkrankungsrisikos von LSBTI Patient*innen und der zugrundeliegenden pathogenetischen Prozesse ist für die psychotherapeutische Praxis relevant. Schlüsselwörter: psychische Krankheit, Gesundheit, Suizid, Lesben, Schwule, Bisexuelle, Homosexualität, Transgender, Intersexualität LSBTI and mental health: Facts and explanatory models Summary: Lesbian, gay, bisexual, transgender, and intersex (LGBTI) individuals seem to be at increased risk for mental disorders and suicidality, as reported in numerous international studies. This paper gives an overview of the current empirical literature and discusses methodological challenges. The evidence for an increase of risk seems to be robust for lesbian, gay, and bisexual individuals; data about transgender and intersex individuals are still rather sparse but hint at an increase of risk, too. Furthermore, this paper discusses current scientific explanatory models about the mental health of LGBTI individuals. These current models overcame old pathologizing views of LGBTI and focus on the impact of society's homo-, bi-, trans-, and interphobia. The resulting different forms of minority stress that LGBTI individuals or those who are perceived as LGBTI are faced with can well explain the increased risk for mental disorders. Being aware of the mental health risk of LGBTI patients and underlying pathogenetic processes is important for psychotherapeutic practice. LGBTI e salute psichica-Fatti e modelli esplicativi Riassunto: Le persone lesbiche, gay, bisessuali, transgender e intersessuali (LGBTI) sembrano avere una predisposizione elevata alle malattie psichiche e al suicidio, come emerge da numerosi studi internazionali. Questo contributo presenta la situazione attuale degli studi e approfondisce le relative sfide metodologiche. Mentre per le persone lesbiche, gay e bisessuali, l'evidenza per un rischio accresciuto di malattia pare solida, i dati relativi al transgenderismo e all'intersessualità sono ancora insufficienti, i risultati anche in questo caso indicano però un rischio elevato. In questo contributo vengono inoltre presentati i più recenti modelli esplicativi scientificamente fondati relativi alla salute psichica di persone LGBTI. Questi hanno sostituito le visioni patologizzanti di LGBTI e si concentrano sulle conseguenze dell'omofobia, bifobia, transfobia e interfobia insite nella società. Le diverse forme di stress da minoranza che ne risultano, alle quali le persone LGBTI, o quelle percepite come tali, sono esposte, rappresentano una buona spiegazione della predisposizione elevata alle malattie. La conoscenza del rischio di malattia delle/dei pazienti LGBTI e dei processi patogenetici che ne sono all'origine, sono rilevanti per la prassi psicoterapeutica.
... Several studies have reported that young people with GD more often show behavioral and emotional problems as compared with peers, and, in particular, significantly higher levels of internalizing problems (i.e., inner-directed and generating distress in the individual) than externalizing ones (i.e., outer-directed and generating discomfort and conflict in the surrounding environment) [2][3][4][5]. In addition, this population suffers from higher rates of suicidality (i.e., suicidal thoughts, suicide attempts, and rates) and self-harm behaviors; in both cases, age has been identified as an important vulnerability factor [6][7][8][9][10]. ...
Article
Purpose Gender dysphoria (GD) is associated with clinically significant distress and impairment in social, scholastic, and other important areas of functioning, especially when early onset is reported. The aim of the present study is to assess the psychopathological features associated with GD in adolescence, comparing a group of gender dysphoric adolescents (GDs) with a group of non-referred adolescents (NRs), in terms of body uneasiness, suicide risk, psychological functioning, and intensity of GD.
... For instance, an important avenue for future research might be to examine whether youth who meets disorder criteria are more likely to continue to self-injure into emerging adulthood. In addition, several inter-(e.g., romantic relationships) and intrapersonal factors (e.g., gender identity; Marshall et al., 2016) that were not examined are subject to future empirical scrutiny. ...
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Although nonsuicidal self-injury (NSSI) peaks in adolescence, a significant proportion of young people continue to self-injure into emerging adulthood. Yet, little is known about factors prospectively associated with persistent NSSI. Using data from a three-year longitudinal study (n = 1466), we compared 51 emerging adults (67.3% female; average age = 20.0) who continued to self-injure from adolescence and 50 emerging adults (83.7% female; average age = 20.3) who had ceased NSSI, on a broad range of psychosocial factors. More frequent NSSI, use of a greater number of methods, specific NSSI functions, academic and emotional distress, and lack of perceived emotion regulatory capability differentiated emerging adults who continued with NSSI and those who had ceased the behavior. Further, the relationships between social support, life satisfaction and NSSI were mediated by perceived ability to regulate emotion. Findings from this study point to the role of personal belief in the ability to effectively regulate emotion in the cessation of NSSI. Future research directions and clinical implications are discussed.
... While there has been recent attention on transgender experience of NSSI, there is still a lack of focus on non-binary transgender identities. Given the known disparities of NSSI across sexual orientation (Batejan, Jarvi, & Swenson, 2015), and evidence of differences between binary gender identities (dickey, Reisner, & Juntunen, 2015;Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016), it is within reason to assume that the experiences of transgender individuals who hold identities outside of the gender binary may vary from one another in experiences of NSSI. In a systematic literature review of the experiences of NSSI and suicidal ideation within transgender populations, only two out of 30 studies included individuals who had an identity outside of the gender binary (McNeil, Ellis, & Eccles, 2017). ...
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The present study used a mixed-method approach to investigate experiences of non-suicidal self-injury (NSSI) among transgender individuals. Participants included 462 adults who had engaged in NSSI within the last five years and who endorsed agender, genderqueer, gender non-conforming, transmasculine and transfeminine transgender identities. Participants completed the Inventory of Statements about Self-Injury (ISAS), the Body Investment Scale (BIS), and an open-ended question regarding their non-suicidal self- injurious experiences. Significant differences were found in BIS subscale scores between individuals with transmasculine and transfeminine identities compared to those with agender, genderqueer, and gender non-conforming identities. In addition, significant differences in subscales scores relevant to interpersonal functioning (ISAS) and comfort in touch (BIS) were found among agender, genderqueer, and gender non- conforming identities, marking increased enjoyment in physical contact for genderqueer individuals compared to gender non-conforming participants, and markedly greater use of interpersonal functions of NSSI for those endorsing an agender identity compared to genderqueer participants. Qualitative data revealed two identity-salient themes for NSSI: reduction of gender dysphoria, and management of mental disorders and chronic illness. Our qualitative analysis uncovered unique ways that NSSI was related to gender dysphoria and other aspects of experience that are not captured in traditional scales of NSSI.
... Fifth, ALSPAC collected sex at birth and did not collect gender at the timepoints in this study. This is important as rates of disordered eating and self-harm are likely to be higher in transgender adults and adolescents [59,60] and there is evidence that transgender adults might have had worse mental health outcomes as a result of the pandemic [61]. Sixth, interpretation of our moderation results is difficult given lifestyle change moderators were not independent of the exposures and outcomes, and may be associated with additional factors such as employment change. ...
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Background Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk. Methods In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May–July 2020) when participants were aged 27–29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April–May 2020) moderated these associations. Results Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing. Conclusions Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals. Plain English summary The aim of this project was to explore the mental health of young adults with disordered eating behaviours (such as fasting, vomiting/taking laxatives, binge-eating and excessive exercise) and self-harm during the COVID-19 pandemic. We analysed data from an established study that has followed children from birth (in 1991 and 1992) up to present day, including during the pandemic when participants were 28 years old. We looked at the relationship between disordered eating and/or self-harm behaviours from before the pandemic and mental health problems (symptoms of depression and anxiety) and mental wellbeing during the pandemic. We also explored whether there were any lifestyle changes (such as changes in sleep, exercise, visiting green space) that might be linked to better mental health and wellbeing in young adults with disordered eating and self-harm. We found that young adults with prior disordered eating and/or self-harm had more symptoms of depression and anxiety, and worse mental wellbeing than individuals without prior disordered eating or self-harm. However, lifestyle changes did not appear to affect mental health and wellbeing in these young adults. Our findings suggest that people with a history of disordered eating and/or self-harm were at high risk for developing mental health problems during the pandemic, and they will need help from mental health services.
... 4 Trans people, people whose gender identity and/or expres- sion differ from the sex assigned to them at birth, have an ele- vated suicide risk in comparison to the general population. [5][6][7][8][9] However, there is a dearth of knowledge about associated fac- tors, particularly concerning protective factors. Suicidality among trans people is associated with high exposure to discrim- ination, victimization, and violence. ...
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Purpose: The aim of this study was to investigate the associations between a series of empirically known risk and protective factors and suicidality among trans people in Sweden. Methods: Participants were self-selected anonymously to a web-based survey conducted in 2014. Univariable and multivariable logistic regression analyses were performed to assess associations between contributing factors and suicide ideation in the past 12 months and lifetime suicide attempts. Results: The analysis included 796 trans individuals, between 15 and 94 years of age, who live in Sweden. A total of 37% of respondents reported that they have seriously considered suicide during the past 12 months and 32% had ever attempted a suicide. Offensive treatment during the past three months and lifetime exposure to trans-related violence were significantly associated with suicidality. Less satisfaction with contacts with friends and acquaintances and with one's own psychological wellbeing were associated with suicide ideation in the past 12 months. Lack of practical support was associated with lifetime suicide attempts. Conclusions: Our findings show that suicidality is directly correlated with trans-related victimization. Preventing targeted victimization is, therefore, a key preventive intervention against this elevated suicidality.
... 4 The RCHGS has seen TGD children and adolescents since 2003, with referrals to the service rising rapidly in the past 5 years from 18 in 2012 to 220 in 2016. 5 In 2015, the RCHGS formalized the service and multidis- ciplinary team in response to the expanding wait list and increasing evidence that TGD young people have considerably higher rates of depression, anxiety, self- harm, and attempted suicide than their cisgender peers, [6][7][8][9] which can, in part, be mitigated by accessing gender-affirming care. 10,11 Included in the multidisci- plinary team is a clinical nurse consultant (CNC), who typically is an advanced practice nurse with masters qualifications, and has advanced nursing knowledge, skills, and attributes relevant to their field with a broad scope of practice. ...
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The Royal Children's Hospital Gender Service offers support, assessment, and medical care to transgender and gender diverse children and adolescents in Victoria, Australia. Referrals have rapidly increased leading to extended wait times. In response, a single-session nurse-led assessment clinic (SSNac) was introduced as the clinical entry point to the service, during which a biopsychosocial assessment is undertaken, and information, education, and support are provided. Outcomes of the SSNac include a significant reduction in wait times and a timely clinical triage system. This article documents the creation and implementation of SSNac to offer a template for use in other gender services.
... The current study found that transgender people who had not under- gone any gender affirming medical interventions reported worse outcomes on all GCLS subscales, the global scale, and two clusters than both cisgender peo- ple and transgender people who had taken cross-sex hormone treatment and undergone genital surgery (C / -chest reconstructive surgery). These findings sup- port previous research that has shown patients to report less distress with their gender, lower levels of body dissatisfaction, better mental well-being, and greater life satisfaction after they had undergone gen- der affirming surgery (e.g., Dhejne et al., 2016;Jones et al., 2016;Marinkovic and Newfield, 2017;Marshall et al., 2016;Murad et al., 2010;van de Grift et al., 2018;Witcomb et al., 2018). This study also found that transgender males who had not undergone any gender affirming medical intervention reported worse outcomes on the chest, other secondary sex characteristics, social gender role recognition, psychological functioning, and life satis- faction subscales of the GCLS, as well as the global scale and the two clusters, than transgender males who had taken cross-sex hormone treatment and undergone chest reconstructive surgery. ...
Article
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Background: It is vital that the treatment offered at transgender health services can be evaluated to ensure a high quality of care. However, the tools currently used to evaluate treatment at transgender health services are limited by mainly focusing on mental health or because they have been developed for binary transgender people only. This study therefore aimed to develop and validate a tool that addresses these limitations. The Gender Congruence and Life Satisfaction Scale (GCLS) was developed through reviewing the literature, conducting interviews with transgender people, and holding discussions with experts working in transgender healthcare. An initial pool of items was developed and feedback on these was obtained. The tool was then validated. Method: For the validation of the tool, a total of 789 participants (451 transgender [171 transgender females, 147 transgender males, 133 people identifying as non-binary], and 338 cisgender [254 females, 84 males]) were recruited from the United Kingdom to test the factor structure and validity of the GCLS. Results: Exploratory factor analysis retained 38 items which formed seven subscales (psychological functioning; genitalia; social gender role recognition; physical and emotional intimacy; chest; other secondary sex characteristics; and life satisfaction). These seven subscales were found to have good internal consistency and convergent validity. The GCLS was also found to be capable of discriminating between groups (e.g., people who have and have not undergone gender affirming medical interventions). Transgender and cisgender subscale norms are provided for the GCLS. Conclusion: The GCLS is a suitable tool to use with the transgender population to measure health-related outcomes for both clinical and research purposes.
... There have been anecdotal reports of adolescents who desisted approximately 9-36 months after showing signs of a rapid onset of gender dysphoria, but longitudinal research following AYAs with gender dysphoria would be necessary to study desistance trends. Although it is still unknown whether transition in gender dysphoric individuals decreases, increases, or fails to change the rates of attempted or completed suicides [64], this study documents AYAs using a suicide narrative as part of their arguments to parents and doctors towards receiving support and transition services. Despite the possibility that the AYAs are using a suicide narrative to manipulate others, it is critical that any suicide threat, ideation or concern is taken seriously and the individual should be evaluated immediately by a mental health professional. ...
... Most research about health disparities that affect gender minorities has focused on mental health (Reisner et al., 2016;Valentine & Shipherd, 2018) and has identified disparities in depression and anxiety (Bockting et al., 2013;Connolly et al., 2016), substance abuse (Staples et al., 2017), suicidality and nonsuicidal self-injury (Marshall et al., 2016;Peterson et al., 2017). However, a recent analysis of Medicare claims data showed that gender minority beneficiaries have higher rates of multiple chronic physical health conditions compared to their cisgender (non-transgender) counterparts (Dragon et al., 2017). ...
Article
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The purpose of this study was to assess gender identity differences in CVD risk and CVD conditions among adults in the U.S. Using data from the 2014–2017 BRFSS we compared CVD risk and CVD conditions in gender minorities (transgender men, transgender women and gender nonconforming persons) to both cisgender men and women. The sample consisted of 662,903 participants. Transgender women (AOR 1.34, 95% CI 1.05–1.72) and transgender men (AOR 1.54, 95% CI 1.07–2.24) were more likely to be overweight than cisgender women. Compared to cisgender women, transgender women reported higher rates of diabetes (AOR 1.45, 95% CI 1.05–1.99), angina/coronary heart disease (AOR 1.90, 95% CI 1.34–2.68), stroke (AOR 1.88, 95% CI 1.16–3.03), and myocardial infarction (AOR 2.98, 95% CI 2.14–4.17). Gender nonconforming participants (AOR 2.68, 95% CI 1.14–6.30) reported higher odds of myocardial infarction than cisgender women. Transgender women also had higher rates of reporting any CVD than cisgender men (AOR 1.38, 95% CI 1.01–1.88). There is a need to elucidate the cardiovascular effects of minority stressors and gender affirming therapy in this population. More research focused on CVD prevention and management in gender minorities is recommended.
... Non-suicidal self-injury behavior has also been found to be significantly more prevalent in the transgender community compared to the general population (Davey, Arcelus, Meyer, & Bouman, 2016). Indeed, a recent systematic literature review found a strong association between gender dysphoria and non-suicidal self-injury ( Marshall et al., 2016), a finding supported by a study of 268 transgender youth that reported that 46.3% had previously or were currently engaging in non-suicidal self-injury behaviors , slightly more than the rate of 36.8% (of a sample of 155) reported in older transgender adults . Parallel to the increasing number of people identifying as transgender, research in the field of transgender health is growing rapidly. ...
... Corresponding to the high numbers of death by suicide, lifetime suicide attempts in selfidentified or individuals with a diagnosis of gender dysphoria are high. In pre-treatment or in mixed pre-treatment and post-treatment groups, around 30% have attempted suicide (Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016;Zucker et al., 2016). Most studies report no gender differences although Landén et al. (1998a) found suicide attempts to be more common in transgender women (23% as compared with 14% in transgender men). ...
... cutting, hitting, and burning oneself), appear to be frequent in transgender individuals and their reduction remains an important health target (Mueller et al., 2017). A recent review by Marshall et al. of 31 articles, concluded that the prevalence of non-suicidal self-injuries and suicidality was higher among transgender individuals than in the non-transpopulation and that transmen (AFAB) were at higher risk (Marshall et al., 2016). A review by McNeil et al. assessed high suicidality rates and confirmed the presence of a strong association between victimization/discrimination/stigma, violence and suicidality and suggested that these stress elements, named ''minority stress'', be considered as risk factors for suicide in transgender individuals (McNeil et al., 2017). ...
Article
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Résumé La recherche épidémiologique peut fournir une clef d’interprétation de l’incongruence de genre (IG) (Gender Incongruence [GI]) et d’identification des besoins médicaux des sujets avec une incongruence de genre. L’IG faisant l’objet de différentes définitions, il est difficile d’estimer sa véritable prévalence. Les données sur la prévalence de l’IG sont influencées par la définition nosographique et par les différentes méthodologies mises en œuvre par les chercheurs pour évaluer les nombres de cas. Selon les estimations existantes, la prévalence, qui présente de larges variations, se situe entre 0,1 % et 1,1 % chez les adultes, avec un ratio homme vers femme (ratio male-to-female [MtF]), femme vers homme (female-to-male [FtM]) de 1-6. Chez les enfants, la littérature rapporte une prévalence entre 1 % et 4,7 %, avec une prédominance du ratio MtF chez les enfants, et de 1,2 % à 16,1 % chez les adolescents pour lesquels le ratio FtM semble prédominant. Les études basées sur l’accès aux cliniques transgenres sont susceptibles de sous-estimer la prévalence de l’IG alors que les études qui mettent l’accent sur les données auto-déclarées ou déclarées par les parents pourraient surestimer le phénomène. La littérature décrit des taux élevés de troubles affectifs et d’anxiété (18–80 %), de fréquents troubles de la personnalité (20–70 %), des tentatives de suicide et des blessures auto-infligées chez les personnes vivant avec une incongruence de genre. Ces problèmes semblent s’améliorer après un traitement d’affirmation de genre. Certains auteurs font état d’une forte prévalence de troubles du spectre autistique (TSA) (Autistic Spectrum Disorders [ASD]) (6–14 %) chez les jeunes avec une incongruence de genre. Les taux de mortalité, les infections VIH et les maladies sexuellement transmissibles sont élevés chez les transgenres, probablement en raison d’un manque de prévention. Il est essentiel de déterminer la véritable prévalence de l’IG afin d’assurer un soutien médical adéquat. Les futures études devraient être basées soit sur de grandes cohortes multicentriques soit sur la population générale, faisant appel à des échantillonnages fondés sur les répondants et comprenant également des sujets qui n’ont pas recours aux services proposés par les cliniques transgenres, afin de minimiser les biais de sélection.
... There is a dearth of research into prevalence of NSSI in non-cisgender individuals. In a systematic analysis, Marshall, Claes, Bouman, Witcomb, and Arcelus (2016) identified only five studies which addressed this relationship. This vulnerable group needs more attention, as transgender participants were found to engage in higher rates of NSSI and suicidality than cisgender participants. ...
Thesis
Non-suicidal self-injury (NSSI) is a maladaptive behaviour, defined as the purposeful destruction of one’s own body tissue performed in absence of suicidal intent or social custom. Research suggests that NSSI is a risk factor for suicidal ideation and suicide attempts. Research also suggests that LGBTQ (lesbian, gay, bisexual, transgender, and queer) identifying individuals are at a higher risk for experiencing mental distress, NSSI and suicidality. Within Aotearoa/New Zealand, the Youth’12: Health and Wellbeing of Secondary School Students survey found that LGBTQ adolescents had significantly higher rates of NSSI and were five times more likely to attempt suicide than their heterosexual and/or cisgender counterparts. This thesis addresses these concerns through a qualitative approach, guided by the methodology of Interpretative Phenomenological Analysis. This research examines how LGBTQ individuals who have previously engaged in NSSI make sense of their experience. The six individuals interviewed share their background histories, the process of coming out, and their experiences with NSSI. Participants further comment on the various ways in which existing ideologies within their social climates impacted their overall health and wellbeing. There were numerous challenges faced by the participants. Some experienced discriminatory behaviours from family, friends, and health professionals. The process of coming out as LGBTQ was a difficult time for many. Participants experienced stigma and discrimination in association with both their identity, and the self-injurious behaviour. NSSI was seen largely as a coping mechanism, and participants displayed resilience in light of their circumstances. Self-esteem and self-acceptance increased as participants acquired a stronger sense of belonging through meaningful connections. Building supportive friendships, and finding a community contributed to positive health outcomes. However, despite a solidified identity, societal pressures remained. The results of this thesis suggest that education and tailored support from health professionals is of utmost importance. The ongoing challenges experienced by the participants are reflected in research, and signify that educating families, health professionals, and the wider society is a crucial step in assisting this at-risk group. Implications for future directions are discussed.
... cutting, hitting, and burning oneself), appear to be frequent in transgender individuals and their reduction remains an important health target (Mueller et al., 2017). A recent review by Marshall et al. of 31 articles, concluded that the prevalence of non-suicidal self-injuries and suicidality was higher among transgender individuals than in the non-transpopulation and that transmen (AFAB) were at higher risk (Marshall et al., 2016). A review by McNeil et al. assessed high suicidality rates and confirmed the presence of a strong association between victimization/discrimination/stigma, violence and suicidality and suggested that these stress elements, named ''minority stress'', be considered as risk factors for suicide in transgender individuals (McNeil et al., 2017). ...
Article
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Epidemiological research may offer a key to interpreting gender incongruence (GI) and identifying the medical needs of people with GI. Currently, it is difficult to estimate the real prevalence of GI due to the use of different definitions. The data on GI prevalence are influenced by case definition and by the different methodologies applied by researchers to assess cases. Estimations of prevalence therefore vary widely and are estimated between 0.1% and 1.1% among adults, with a male-to-female (MtF) – female-to-male (FtM) sex ratio of 1–6. For children, the literature reports a prevalence ranging from 1% to 4.7%, with a predominance of MtF for children and from 1.2% to 16.1% in adolescents, among whom FtM appears to be predominant. Studies based on access to gender clinics may underestimate GI prevalence while studies focused on self- or parent-reported data may overestimate the phenomenon. The literature describes high rates of affective and anxiety disorders (18–80%) and frequent personality disorders (20–70%), suicide attempts, suicide and self-harm among people with GI. These problems seem to improve after gender affirmation treatment. Some authors report a high prevalence of Autistic Spectrum Disorders (ASD) (6–14%) among youth with GI. Mortality rates, HIV infection and sexually transmitted diseases are high among the transgender population, probably related to lack of prevention. It is crucial to determine the true prevalence of GI in order to deliver adequate medical support. Future studies should be based on large multicenter cohorts or population-based surveys, and should adopt respondent-driven sampling while including individuals who do not seek services offered at gender clinics, to limit the selection bias.
... The authors of this article could identify only one previous literature review investigating the prevalence of self-injury among gender-diverse populations in the United Kingdom. That review, however, considered academic literature published between 1966 and 2015, transgender individu- als of all ages and literature from across all countries ( Marshall et al., 2016). The current review, by contrast, aimed to investigate the prevalence of SITBs, both suicidal and non-suicidal, among CYP in the United Kingdom identifying as a gender not typically associated with the sex they were assigned at birth. ...
Article
International literature suggests that gender-diverse people are at increased risk of thoughts and acts of self-injury compared to their cisgender peers. The current review aimed to investigate the prevalence of self-injurious thoughts and behaviours (SITBs) among children and young people (CYP) in the United Kingdom identifying as a gender not typically associated with the sex they were assigned at birth and, further, to examine relevant prevalence rates of SITBs reported both in academic and grey literature. In total, seven studies were included in the review and indicated an increased prevalence of SITBs among gender-diverse CYP compared to the general population. However, methodological limitations and significant heterogeneity in the rates of SITBs reported require that the available literature be interpreted with some caution. Important factors to consider when interpreting SITB rates, as well as recommendations for future research, are discussed.
... Based on self-report data from community and gender-referred samples of transgender youth, rates of suicidal thoughts may range from 45% to 51% and rates of suicidal behaviors may range from 26% to 30% (Grossman & D'Augelli, 2007;Olson, Schrager, et al., 2015). The heightened risk for suicidal thoughts and behaviors appears to extend from childhood through adulthood (e.g., Aitken et al., 2016;Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016). Children referred to specialized clinics for genderidentity-related issues are more likely to endorse suicidal ideation and self-injurious behaviors than both nonreferred cisgender children and sibling comparison groups (Aitken et al., 2016). ...
Article
Transgender children and adolescents experience a gender identity that is incongruent with their sex assigned at birth, often resulting in gender dysphoria. Emerging literature has explored the etiology of transgender identities, documented transgender youths’ risk for psychopathology, and evaluated whether social and medical gender transition processes are appropriate and effective for transgender youth. However, there is a dearth of empirical data on gender-affirmative psychological interventions designed to reduce the forms of psychological distress experienced by many transgender youths. This is surprising given the elevated rates of psychological distress among transgender youth and the broad recommendation for psychotherapy for youth going through a gender transition. To identify future directions in psychological interventions for transgender youth, we first review key background information on transgender youths’ identity development and the role of psychological support in affirmative care. Next, we present future directions in this literature, which emphasizes the need for theory-driven empirical research that incorporates the developmental context of transgender youth to understand the mechanisms underlying group-specific psychological distress. Finally, we lay out the application of these future directions by exploring 3 domains relevant to transgender youth’s psychological distress: gender dysphoria, parent and peer interactions, and co-occurring psychopathology. Within each domain, we review extant empirical research, present the current state of affirmative psychological interventions, and discuss implications for future directions. Future research on affirmative psychological care for transgender youth is urgently needed and must focus on clearly articulating which youth could benefit from psychological interventions and why those interventions might be effective.
... Transgender people are exposed to negative health determinants as a consequence of societal stigmatisation (Heath and Wynne 2019). This leads to greater rates of suicidality and mental health issues, HIV exposure and drug and alcohol use (Marshall et al. 2016). The mental health sequelae have reached crisis-point for Australian trans-youth (Strauss et al. 2017). ...
Article
Transgender individuals who desire medical transition need to access care through their local healthcare system. This is the first study to explore the perceptions of the community and attitudes of healthcare providers towards the delivery of transgender health care in an Australian context. An anonymous survey was conducted of trans and gender-diverse community members; and physicians and trainees in the Hunter New England Local Health District of New South Wales, Australia. Community members were surveyed about their healthcare experiences. Medical students, GPs and hospital physicians were surveyed on their attitudes towards the delivery of transgender health care before and after a 1-h education session that included the lived experience of a community member. Community members expressed a need for increased education for healthcare providers in transgender medicine. Following the intervention, significantly more healthcare providers felt confident to facilitate transgender health care for adults, adolescents and children; and more healthcare providers agreed that medical and surgical treatment should be offered to transgender patients if desired. The positive safety profile of treatment was felt to be the most persuasive factor for the provision of care. Healthcare providers identified a need for health education in transgender medicine; easy access to evidence-based resources; and local referral pathways as key strategies to improving transgender health care.
Article
Introduction. As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. Aims. The aim of this study was to investigate the socio-demographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. Methods. Every individual over the age of 50 years old referred to a national gender identity clinic during a thirty months period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. Main Outcome Measures. Socio-demographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimisation (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and non-suicidal self-injury (Self-Injury Questionnaire). Results. The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n=3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, divorced and had children. Trans females on CHT that came out as trans and transitioned at an earlier age, were significantly less anxious, reported higher levels of self-esteem and presented with less socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem, remained. Conclusion. The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.
Research
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German paper about the role of bullying to explain sexual orientation disparities in suicide risk
Article
Background: Anxiety disorders pose serious public health problems. The data available on anxiety disorders in the transgender population is limited by the small numbers, the lack of a matched controlled population and the selection of a nonhomogenous group of transgender people. Aims: The aims of the study were (1) to determine anxiety symptomatology (based on the HADS) in a nontreated transgender population and to compare it to a general population sample matched by age and gender; (2) to investigate the predictive role of specific variables, including experienced gender, self-esteem, victimization, social support, interpersonal functioning, and cross-sex hormone use regarding levels of anxiety symptomatology; and (3) to investigate differences in anxiety symptomatology between transgender people on cross-sex hormone treatment and not on hormone treatment. Methods: A total of 913 individuals who self-identified as transgender attending a transgender health service during a 3-year period agreed to participate. For the first aim of the study, 592 transgender people not on treatment were matched by age and gender, with 3,816 people from the general population. For the second and third aim, the whole transgender population was included. Measurements: Sociodemographic variables and measures of depression and anxiety (HADS), self-esteem (RSE), victimization (ETS), social support (MSPSS), and interpersonal functioning (IIP-32). Results: Compared with the general population transgender people had a nearly threefold increased risk of probable anxiety disorder (all p < .05). Low self-esteem and interpersonal functioning were found to be significant predictors of anxiety symptoms. Trans women on treatment with cross-sex hormones were found to have lower levels of anxiety disorder symptomatology. Conclusions: Transgender people (particularly trans males) have higher levels of anxiety symptoms suggestive of possible anxiety disorders compared to the general population. The findings that self-esteem, interpersonal functioning, and hormone treatment are associated with lower levels of anxiety symptoms indicate the need for clinical interventions targeting self-esteem and interpersonal difficulties and highlight the importance of quick access to transgender health services.
Article
Transgender (trans) individuals have historically been left out of research, and previous work has often conflated gender identity with sexual orientation. Furthermore, language used in psychology measures is often heteronormative and uses binary gendered language (e.g., “him”/“her”). The aim of the current study was to provide empirically derived guidance on conducting culturally sensitive research with transgender participants using qualitative data. We recruited trans individuals, ages 18 to 44, to participate in an anonymous, qualitative, national online survey as part of a quantitative study on the relationships among minority stress, sexual behavior, and mental health. The qualitative portion included four open-ended feedback questions. We identified four overarching themes regarding experiences with our survey: (a) emotional reaction; (b) insight gained; (c) being outside the box; and (d) value of the work. Research with trans adults should be more inclusive of diverse gender identities, sexual identities, and sexual behaviors. Steps in this direction may include soliciting feedback from community members regarding survey language and response options, allowing participants to contextualize their responses using open-ended questions, and clarifying language to distinguish between sexual behavior and sexual identity. A list of seven preliminary guidelines was proposed to aid scientists in conducting culturally sensitive research with trans individuals.
Article
Gender affirming treatment for transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen lowering medications. Feminizing treatment with estrogens and anti-androgens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk of venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses plus increase of muscle mass, facial and body hair. Due to the lack of evidence, treatment for gender non-binary people should be individualized. Young people may receive pubertal suspension, consisting of gonadotrophin-releasing hormone analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur, but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to effect of gender affirming treatment in the non-binary population.
Article
Purpose: Gender dysphoria (GD) is associated with clinically significant distress and impairment in social, scholastic, and other important areas of functioning, especially when early onset is reported. The aim of the present study is to assess the psychopathological features associated with GD in adolescence, comparing a group of gender dysphoric adolescents (GDs) with a group of non-referred adolescents (NRs), in terms of body uneasiness, suicide risk, psychological functioning, and intensity of GD. Methods: A sample of 46 adolescents with GD and 46 age-matched NRs was evaluated (mean ± SD age = 16.00 ± 1.49 and 16.59 ± 1.11 respectively, p > 0.05). Subjects were asked to complete the Body Uneasiness Test (BUT) to explore body uneasiness, the Youth Self Report (YSR) to measure psychological functioning, the Multi-Attitude Suicide Tendency Scale (MAST) for suicide risk, and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) for GD assessment. Results: Adolescents with GD reported significantly higher levels of body uneasiness (BUT-GSI, F = 380.13, p < 0.0001), as well as a worse psychological functioning (YSR, F = 13.06 and p < 0.0001 for "total problem scale" and F = 12.53, p = 0.001 for "internalizing" scale) as compared to NRs. When YSR subscales were considered, GDs showed significantly higher scores in the "withdrawal/depression", "anxiety/depression", and "social problems" (all p < 0.0001). In addition, GDs showed significantly higher levels in the "attraction to death" and "repulsion by life" scales and lower scores in the "attraction to life" scale (all p < 0.0001). Finally, GIDYQ-AA score was significantly lower (meaning a higher level of gender dysphoria symptoms) in GDs vs. NRs (p < 0.0001). Conclusions: GD adolescents reported significantly higher body dissatisfaction and suicidal risk compared to NRs. In addition, results confirmed a significant impairment in social psychological functioning in adolescents with GD.
Article
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Purpose: This article reports on the findings of a meta-synthesis undertaken on published gray transgender suicidality literature, to determine the average rate of suicidal ideation and attempts in this population. Methods: Studies included in this synthesis were restricted to the 42 that reported on 5 or more Canadian or U.S. adult participants, as published between 1997 and February 2016 in either gray or peer-reviewed health literature. Results: Across these 42 studies an average of 55% of respondents ideated about and 29% attempted suicide in their lifetimes. Within the past year, these averages were, respectively, 51% and 11%, or 14 and 22 times that of the general public. Overall, suicidal ideation was higher among individuals of a male-to-female (MTF) than female-to-male (FTM) alignment, and lowest among those who were gender non-conforming (GNC). Conversely, attempts occurred most often among FTM individuals, then decreased for MTF individuals, followed by GNC individuals. Conclusion: These findings may be useful in creating targeted interventions that take into account both the alarmingly high rate of suicidality in this population, and the relatively differential experience of FTM, MTF, and GNC individuals. Future research should examine minority stress theory and suicidality protection/resilience factors, particularly transition, on this population.
Article
Transgender individuals are at increased risk for suicide relative to nontransgender people. Despite this, research on transgender people's risk for suicide mirrors their marginalization at the societal level; there is simply not enough research dedicated to understanding increased suicide risk among transgender people. This article presents a brief review of what is known regarding the prevalence and correlates of suicide-related thoughts and behaviors among transgender people and offers perspective regarding what theories of suicide may be pertinent to understanding and addressing increased suicide risk within this population. We also summarize strengths and limitations of the current body of work to provide impetus for additional and improved research on this important problem.
Article
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The International Diabetes Federation estimates that approximately 0.4% of the Belgian population is diagnosed with type 1 diabetes mellitus, which is similar to other industrialized countries. The prevalence of transgenderism is estimated at 0.6% to 0.7% of all adults in Western populations. In this study, we evaluated whether there was an increased prevalence of type 1 diabetes mellitus in transgender people in the local cohort. Medical records of transgender patients were analyzed retrospectively. From January 1, 2007 until October 10, 2016, 1,081 transgender patients presented at a tertiary reference center to start hormonal treatment. Nine of these 1,081 patients were previously diagnosed with type 1 diabetes mellitus and 1 was diagnosed with latent autoimmune diabetes in adults. A 2.3-fold higher prevalence of type 1 diabetes mellitus was observed in transgender patients. We concluded that type 1 diabetes mellitus was more prevalent in transgender patients than one would expect from population prevalences. This could be a spurious result in a local cohort, because a causal relation seems unlikely, but our finding might encourage other centers to investigate this putative association. Defreyne J, De Bacquer D, Shadid S, et al. Is Type 1 Diabetes Mellitus More Prevalent Than Expected in Transgender Persons? A Local Observation. Sex Med 2017;5:e215–e218.
Article
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Objective: To compare the presence of criteria listed in the DSM-5 and ICD-10 diagnostic manuals in a Brazilian sample of transgender persons seeking health services specifically for physical transition. Methods: This multicenter cross-sectional study included a sample of 103 subjects who sought services for gender identity disorder in two main reference centers in Brazil. The method involved a structured interview encompassing the diagnostic criteria in the two manuals. Results: The results revealed that despite theoretical disagreement about the criteria, the manuals overlap regarding diagnosis confirmation; the DSM-5 was more inclusive (97.1%) than the ICD-10 (93.2%) in this population. Conclusions: Although there is no consensus on diagnostic criteria on transgenderism in the diversity of social and cultural contexts, more comprehensive diagnostic criteria are evolving due to society's increasing inclusivity.
Article
Purpose: This study examined internalized transnegativity and psychological distress in two age groups of transgender individuals who identified their gender identity on the feminine spectrum (rather than congruent with their male sex assigned at birth). Due to greater visibility and acceptance of gender diversity in the United States, we hypothesized that internalized transnegativity would be lower in the younger compared with the older group, and that the younger generation would, therefore, report lower levels of psychological distress than the older generation. Methods: The study sample consisted of trans-feminine individuals (N = 440) who completed a online survey of the U.S. transgender population and comprised a younger group aged 18-24 years (n = 133) and an older group aged 40 years and older (n = 307). Internalized transnegativity was assessed using the Transgender Identity Survey, and psychological distress was assessed with the Brief Symptom Inventory 18. We used regression and mediation analysis to examine differences between the two groups. Results: Contrary to our expectations, the older group reported significantly lower levels of both internalized transnegativity and psychological distress compared with the younger group. Internalized transnegativity partially mediated the relationship between age group and psychological distress. Conclusion: Despite greater visibility of transgender people and increasing acceptance of gender diversity in the United States, the younger trans-feminine individuals reported more psychological distress than the older transfeminine individuals, which was, in part, related to internalized transnegativity. Trans-feminine individuals may benefit from culturally sensitive and clinically competent mental health services to alleviate internalized transnegativity and psychological distress.
Article
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Introduction:Individuals with gender identity disorder (GID) experienceseries of adjustment problems in society before and after sex reassignment surgery. The aim of this study was to compare self-harm and defense mechanisms before and after sex reassignment surgery in these persons. Method: We used a case- control design, in quantitative stage 30 people with GID before surgery and 30 people with GID after surgery and normal people were investigated. Results:Data analysis by a Multivariate analysis of variance were showndecreasedtrend of directly self-harm behaviors after surgery, whereas there were not any differences in indirect self-harm behaviors before and after surgery. No differences was found in neurotic and mature defense mechanisms between groups. Conclusion: It seemthat the sex reassignment surgery could effectivelydecreasethe directly self-harm and immature defense mechanisms, while it has no effect in changing indirect self-harm, neurotic and mature defense mechanisms. It could be concluded that indirect self-harm sustains even after sex reassignment surgery that need to be targeted with psychological and social interventions. Changing in the immature defense mechanisms could be considered as a valid indicator of physical and psychological treatments.
Article
Background : Previous research has consistently reported high rates of mental health symptomatology and lower social support in young treatment seeking transgender individuals. However, these studies have failed to distinguish between transgender people who identify within the gender binary and those who identify as non-binary. Aims : This study aimed to compare levels of mental health symptomatology (anxiety, depression, and non-suicidal self-injury behavior) and social support of treatment seeking non-binary transgender young individuals with those self-identified as binary transgender young individuals. All participants attended a national transgender health service in the UK during a 2-year period. Measures : Age and gender identity descriptors were collected, as well as clinical measures of anxiety and depression (Hospital Anxiety and Depression Scale), self-esteem (The Rosenberg Self-Esteem Scale), non-suicidal self-injury (Non-Suicidal Self-Injury: Treatment Related), and social support (Multidimensional Scale of Perceived Social Support). Results : A total of 388 young people, aged 16-25 years, agreed participation; 331 (85.3%) identified as binary and 57 (14.7%) as non-binary. Analysis of the data showed the non-binary group experienced significantly more anxiety and depression and had significantly lower self-esteem than the binary group. There were no significant differences between groups in the likelihood of engaging in non-suicidal self-injury behavior or levels of social support. Conclusions : Non-binary identifying treatment seeking transgender youth are at increased risk of developing anxiety, depression, and low self-esteem compared to binary transgender youth. This may reflect the even greater barriers and feelings of discrimination that may be faced by those whose identity does not fit the notion of binary gender that is pervasive in how society views both cis- and transgender populations.
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Background: Previous research has reported high levels of non-suicidal self-injury (NSSI) in trans populations and younger age has been identified as a risk factor. Aims: To explore the prevalence of NSSI in a large group of young trans people, and to identify risk factors for this group. Main Outcome Measures: Socio-demographic variables and measures of NSSI (The Self-Injury Questionnaire), Psychopathology (Symptom Checklist 90 Revised), Self-esteem (Rosenberg Self Esteem Scale), victimization (Experiences of transphobic victimization), Interpersonal functioning (Inventory of Interpersonal Problems) and social support (Multidimensional Scale of Perceived Social Support). Methods: Two hundred and sixty eight young people attending a national gender clinic completed questionnaires assessing presence and frequency of NSSI and levels of general psychopathology, depression, anxiety, interpersonal problems, self-esteem, social support, transphobia, and information on hormone treatment. Results: A life-time presence of NSSI was identified in 46.3% of patients and 28.73% reported currently engaging in NSSI (within at least the last few months). Analyses showed that those with a life-time presence of NSSI had significantly greater general psychopathology, lower self-esteem, had suffered more transphobia, and experienced greater interpersonal problems than those without NSSI. Findings were similar when comparing current versus non-current NSSI. Overall, natal males reported less social support than natal females, but current NSSI was more common in natal females. Regression analyses confirmed that natal female gender and greater general psychopathology predicted both current and life-time NSSI. Further analyses confirmed that general psychopathology itself could be predicted by transphobic experiences, low self-esteem, and interpersonal problems, but not by the use of cross sex hormones. Conclusions: These findings confirm that NSSI is common in trans youth and emphasise the need for interventions, which decrease transphobia, increase social support and help trans youth navigate their relationships with others in order to reduce psychopathology and NSSI.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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The Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria is a publication of the Intercollegiate Committee of the Royal College of Psychiatrists. The overall goal of the Good Practice Guidelines is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynaecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counselling, psychotherapy), and hormonal and surgical treatments. The Good Practice Guidelines are based on the best available science and expert professional consensus. The Good Practice Guidelines articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, the Good Practice Guidelines recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the Good Practice Guidelines to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
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This Briefs is the first national study on female-to-male (FtM) transgender people’s experiences in Australia. It describes an extensive study that fills the current gap in Australian research on the specific experiences and beliefs about transition for contemporary Australian FtM transgender people. Following an overview of current literature on the various aspects of and approaches to transgender issues, this briefs describes in detail the design, participants and findings of the study. The Briefs offers useful statistics and stories related to participants' identities, education, health, sexual and social lives. It ends with recommendations to all those working in the various offices and institutions that FtM transgender people encounter in their everyday life, and represents and invaluable resource for researchers, service providers and gender diverse communities alike.
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This article presents the findings from a cross-sectional study on demographic variables and associated difficulties in 218 children and adolescents (Mean age = 14 years, SD = 3.08, range = 5-17 years), with features of gender dysphoria, referred to the Gender Identity Development Service (GIDS) in London during a 1-year period (1 January 2012-31 December 2012). Data were extracted from patient files (i.e. referral letters, clinical notes and clinician reports). The most commonly reported associated difficulties were bullying, low mood/depression and self-harming. There was a gender difference on some of the associated difficulties with reports of self-harm being significantly more common in the natal females and autism spectrum conditions being significantly more common in the natal males. The findings also showed that many of the difficulties increased with age. Findings regarding demographic variables, gender dysphoria, sexual orientation and family features are reported, and limitations and implications of the cross-sectional study are discussed. In conclusion, young people with gender dysphoria often present with a wide range of associated difficulties which clinicians need to take into account, and our article highlights the often complex presentations of these young people. © The Author(s) 2014.
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Purpose: U.S. health surveillance systems infrequently include measures to identify transgender respondents or monitor the health of this underserved and marginalized population. Methods: From 2001-2002, transgender and non-transgender adults were sampled at a Massachusetts clinic. Health differences were formatively examined by transgender identity using a cross-sectional, clinic-based sample (n=2,653); and a nested matched-pair subsample (n=155). Results: Both designs produced virtually identical findings: (1) the prevalence of HIV, substance abuse, and smoking did not differ significantly for transgender and non-transgender patients; (2) transgender patients were more likely to endorse a lifetime suicide attempt and ideation compared to non-transgender patients (p<0.05); (3) transgender patients disproportionately reported social stressors (violence, discrimination, childhood abuse) relative to non-transgender patients (p<0.05). Conclusion: Findings suggest that a nested design may provide an effective methodology for using clinical data to study transgender health, and underscore the need for routine collection of gender identity in clinical settings.
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This article presents the findings from an audit on self-harm in 125 children and adolescents referred to the Gender Identity Development Service in London. Data concerning selfharming thoughts and behaviors before attending the service were extracted from documents in the patient files and from clinician reports. The findings indicated that suicide attempts and self-harming were more common over the age of 12. Overall, thoughts of self-harm were more common in the natal males whereas actual self-harm was more common in the natal females. The number of suicide attempts did not differ significantly between the two genders. The implications of these findings are discussed. Limitations of the study are also discussed which include that the data was only collected over an 8-month period and that it was extracted from patient files and from clinician reports.
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Mental illness affects the lives of a significant number of Australians. In addition to pharmacological and psychological interventions, exercise has demonstrated benefits for people with mental illness including symptom reduction, improved cardiovascular risk profile and improved physical capacity. Unfortunately, evidence shows that clinician-delivered exercise advice is not routinely offered. This is despite patient acceptability for exercise. This article summarises the recent evidence supporting the prescription of exercise for people with mental illness and offers a model incorporating basic exercise prescription, and referral pathways for specialised advice. Current exercise prescription patterns for people with mental illness may not meet patient expectations; therefore, clinicians should consider exercise referral schemes to increase the accessibility of interventions for people with a mental illness.
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The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
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Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.
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A recent study indicated a suicide attempt rate of 41 % among trans (e.g., trans, transgender, transexual/transsexual, genderqueer, two-spirit) individuals. Although this rate is alarming, there is a dearth of literature regarding suicide prevention for trans individuals. A vital step in developing suicide prevention models is the identification of protective factors. It was hypothesized that social support from friends, social support from family, optimism, reasons for living, and suicide resilience, which are known to protect cis (non-trans) individuals, also protect trans individuals. A sample of self-identified trans Canadian adults (N = 133) was recruited from LGBT and trans LISTSERVs. Data were collected online using a secure survey platform. A three block hierarchical multiple regression model was used to predict suicidal behavior from protective factors. Social support from friends, social support from family, and optimism significantly and negatively predicted 33 % of variance in participants' suicidal behavior after controlling for age. Reasons for living and suicide resilience accounted for an additional 19 % of the variance in participants' suicidal behavior after controlling for age, social support from friends, social support from family, and optimism. Of the factors mentioned above, perceived social support from family, one of three suicide resilience factors (emotional stability), and one of six reasons for living (child-related concerns) significantly and negatively predicted participants' suicidal behavior. Overall, these findings can be used to inform the practices of mental health workers, medical doctors, and suicide prevention workers working with trans clients.
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Research has documented significant relationships between sexual and gender minority stress and higher rates of suicidality (i.e. suicidal ideation and attempts) and substance use problems. We examined the potential mediating role of substance use problems on the relationship between sexual and gender minority stress (i.e. victimization based on lesbian, gay, bisexual, or transgender identity [LGBT]) and suicidality. A nonprobability sample of LGBT patients from a community health center (N = 1457) ranged in age from 19-70 years. Participants reported history of lifetime suicidal ideation and attempts, substance use problems, as well as experiences of LGBT-based verbal and physical attacks. Substance use problems were a significant partial mediator between LGBT-based victimization and suicidal ideation and between LGBT-based victimization and suicide attempts for sexual and gender minorities. Nuanced gender differences revealed that substance use problems did not significantly mediate the relationship between victimization and suicide attempts for sexual minority men. Substance use problems may be one insidious pathway that partially mediates the risk effects of sexual and gender minority stress on suicidality. Substances might be a temporary and deleterious coping resource in response to LGBT-based victimization, which have serious effects on suicidal ideation and behaviors.
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Abstract The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.
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We examined the frequency and predictors of suicide attempts among gender minority individuals (N = 153) who were recruited at a transgender conference. Eighteen percent of the participants reported a past suicide attempt, with trans men reporting the highest rate of suicide attempts (41%), followed by trans women (20%). Factors associated with having a past suicide attempt included female sex assigned at birth, psychiatric hospitalisations, and having experienced transgender-related violence. Implications of these data are considered in the context of intervention development for this at-risk group.
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This study examined the relation between sexual orientation and suicidality among 73 transgender respondents, who were compared to heterosexual females (n = 1,083) and males (n = 1,077), psychosocially matched females (n = 73) and males (n = 73), and homosexual females (n = 256) and males (n = 356). Significantly more (p < .05)transgender respondents reported suicide ideation and attempts than any group except homosexual females. Sexual orientation did not differentiate transgender ideators or attempters from non-ideators or non-attempters. Attempters were more likely than non-attempters to report psychotherapy and psychiatric medications currently and previously as well as difficulties with both alcohol and drugs (attempters and ideators) or alcohol only (attempters). Implications for gender studies as well as research regarding suicide and sexual orientation are discussed.
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This short-term prospective study examined general and lesbian, gay, bisexual, and transgender (LGBT)-specific risk and protective factors for suicide attempts in an ethnically diverse sample of LGBT youth (N = 237, 47.7 % male). A structured psychiatric interview assessed clinical depression and conduct disorder symptoms, as well as past and prospective suicide attempts over a 1-year follow-up period (91 % retention). Participants completed questionnaires measuring general risk factors for suicide attempts, including hopelessness, impulsiveness, and perceived social support. They also completed measures of LGBT-specific suicide risk factors, including gender nonconformity, age of first same-sex attraction, and LGBT victimization. Correlation and multivariate regression analyses were conducted to examine the relations between predictors and suicide attempt, and to identify mediators. Of nine variables examined, seven were related to lifetime history of attempted suicide: hopelessness, depression symptoms, conduct disorder symptoms, impulsivity, victimization, age of first same-sex attraction, and low family support. Depressive symptoms and hopelessness mediated the relation between multiple risk and resilience factors and suicide attempts. Suicide attempt history was the strongest predictor of prospective suicide attempts. Participants who previously attempted suicide (31.6 % of the sample) had more than 10 times greater odds of making another attempt in the 1-year follow-up period than were those who had made no previous attempt. These results highlight the need for suicide prevention programs for LGBT youth and suggest the importance of addressing depression and hopelessness as proximal determinants and family support and victimization, which have more distal effects.
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Using secondary analyses of data from a sample of 265 sexual minority youths, the authors examined correlates of cutting behavior to determine whether patterns are similar to those found in studies of self-injury with community samples of predominately heterosexual youths. The sample consisted of youths who received services at an urban social service agency serving the sexual minority community, youths from the region attending social events, who located the survey through the Internet, or who were referred from other youth-serving agencies; and youths from out of state who found the survey through the Internet or were referred by youth-serving agencies. Prevalence of cutting was higher than that found in community-based samples of similar age groups. However, similar patterns of risk were found with regard to peer victimization, homelessness, suicidality, and depression. Female and transgender respondents were more likely to have engaged in cutting behavior than were male respondents. No significant
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The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment. To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons. A population-based matched cohort study. Sweden, 1973-2003. All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively. Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]). The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls. Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.
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Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones. A cohort study with a median follow-up of 18.5 years at a university gender clinic. Methods Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses. In the MtF group, total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-specific mortality were not significantly different from those of the general population. The increased mortality in hormone-treated MtF transsexuals was mainly due to non-hormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death. In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.
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Despite strong indications of elevated risk of suicidal behavior in lesbian, gay, bisexual, and transgender people, limited attention has been given to research, interventions or suicide prevention programs targeting these populations. This article is a culmination of a three-year effort by an expert panel to address the need for better understanding of suicidal behavior and suicide risk in sexual minority populations, and stimulate the development of needed prevention strategies, interventions and policy changes. This article summarizes existing research findings, and makes recommendations for addressing knowledge gaps and applying current knowledge to relevant areas of suicide prevention practice.
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We examined associations of race/ethnicity, gender, and sexual orientation with mental disorders among lesbian, gay, bisexual, and transgender (LGBT) youths. We assessed mental disorders by administering a structured diagnostic interview to a community sample of 246 LGBT youths aged 16 to 20 years. Participants also completed the Brief Symptom Inventory 18 (BSI 18). One third of participants met criteria for any mental disorder, 17% for conduct disorder, 15% for major depression, and 9% for posttraumatic stress disorder. Anorexia and bulimia were rare. Lifetime suicide attempts were frequent (31%) but less so in the prior 12 months (7%). Few racial/ethnic and gender differences were statistically significant. Bisexually identified youths had lower prevalences of every diagnosis. The BSI 18 had high negative predictive power (90%) and low positive predictive power (25%) for major depression. LGBT youths had higher prevalences of mental disorder diagnoses than youths in national samples, but were similar to representative samples of urban, racial/ethnic minority youths. Suicide behaviors were similar to those among representative youth samples in the same geographic area. Questionnaires measuring psychological distress may overestimate depression prevalence among this population.
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This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69%) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At follow-up, 32 patients had completed sex reassignment surgery, five were still in process, and five-following their own decision-had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5-15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years), and non-homosexually oriented (56 vs. 15%). In conclusion, almost all patients were satisfied with the sex reassignment; 86% were assessed by clinicians at follow-up as stable or improved in global functioning.
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A long-term follow-up study of 55 transsexual patients (32 male-to-female and 23 female-to-male) post-sex reassignment surgery (SRS) was carried out to evaluate sexual and general health outcome. Relatively few and minor morbidities were observed in our group of patients, and they were mostly reversible with appropriate treatment. A trend toward more general health problems in male-to-females was seen, possibly explained by older age and smoking habits. Although all male-to-females, treated with estrogens continuously, had total testosterone levels within the normal female range because of estrogen effects on sex hormone binding globulin, only 32.1% reached normal free testosterone levels. After SRS, the transsexual person's expectations were met at an emotional and social level, but less so at the physical and sexual level even though a large number of transsexuals (80%) reported improvement of their sexuality. The female-to-males masturbated significantly more frequently than the male-to-females, and a trend to more sexual satisfaction, more sexual excitement, and more easily reaching orgasm was seen in the female-to-male group. The majority of participants reported a change in orgasmic feeling, toward more powerful and shorter for female-to-males and more intense, smoother, and longer in male-to-females. Over two-thirds of male-to-females reported the secretion of a vaginal fluid during sexual excitation, originating from the Cowper's glands, left in place during surgery. In female-to-males with erection prosthesis, sexual expectations were more realized (compared to those without), but pain during intercourse was more often reported.
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This review highlights recent work evaluating the relationship between exercise, physical activity and physical and mental health. Both cross-sectional and longitudinal studies, as well as randomized clinical trials, are included. Special attention is given to physical conditions, including obesity, cancer, cardiovascular disease and sexual dysfunction. Furthermore, studies relating physical activity to depression and other mood states are reviewed. The studies include diverse ethnic populations, including men and women, as well as several age groups (e.g. adolescents, middle-aged and older adults). Results of the studies continue to support a growing literature suggesting that exercise, physical activity and physical-activity interventions have beneficial effects across several physical and mental-health outcomes. Generally, participants engaging in regular physical activity display more desirable health outcomes across a variety of physical conditions. Similarly, participants in randomized clinical trials of physical-activity interventions show better health outcomes, including better general and health-related quality of life, better functional capacity and better mood states. The studies have several implications for clinical practice and research. Most work suggests that exercise and physical activity are associated with better quality of life and health outcomes. Therefore, assessment and promotion of exercise and physical activity may be beneficial in achieving desired benefits across several populations. Several limitations were noted, particularly in research involving randomized clinical trials. These trials tend to involve limited sample sizes with short follow-up periods, thus limiting the clinical implications of the benefits associated with physical activity.
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Although often used as synonyms, "self-injury" and "self-harm" may refer to different behaviors with different meanings. Because the literature is quite confusing in this respect, we propose a more specific delineation of the notion of self-injurious behavior (SIB), differentiated from other self-harming behaviors. For this purpose, we present a flowchart for differential diagnosis. This brings us to the question: are we dealing here with a sign of pathology or a meaningful behavior? We compare the structuralist approach, in which SIB is viewed as either a syndrome or a symptom, with the functionalist approach, focusing on the psychosocial functions of SIB.
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This study aims to determine the prevalence rate of current non-suicidal self-injury (NSSI) among trans individuals, in comparison with a control sample of non-trans adults. It also aims to compare those with current NSSI and those with no history of NSSI in terms of psychological well-being, self-esteem, body dissatisfaction, social support and demographic factors. Participants were 97 adults, diagnosed with transsexualism (ICD-10, F64.0), attending a national gender clinic in the United Kingdom, and a matched control group. Clinical participants were all engaged on the treatment pathway. Participants completed the following self-report measures: Self-Injury Questionnaire - Treatment Related (SIQ-TR), Symptom Checklist 90 Revised (SCL-90-R), Rosenberg Self-Esteem Scale (RSE), Hamburg Body Drawing Scale (HBDS) and Multidimensional Scale of Perceived Social Support (MSPSS). The results showed that the trans participants had a significantly higher prevalence of current NSSI behaviour than the non-trans group, with 19% currently engaging in NSSI. Current NSSI was also significantly more prevalent among trans men than trans women. Compared with both trans and non-trans participants with no history of NSSI, trans participants with current NSSI had significantly higher scores on SCL; significantly lower scores on RSE, HBDS and MSPSS; and were younger in age. The study concludes that trans men, specifically, are more at risk of NSSI than trans women and the general population, even when on the treatment pathway. Those who currently self-injure have greater psychopathology, lower body satisfaction, lower self-esteem, lower social support and tend to be younger, than those who do not engage in NSSI. © 2015 John Wiley & Sons Ltd.
Article
Background: Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data. Methods: Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed. Results: The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years. Conclusions: The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.
Article
The mental health and victimization of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth have garnered media attention with the "It Gets Better Project." Despite this popular interest, there is an absence of empirical evidence evaluating a possible developmental trajectory in LGBTQ distress and the factors that might influence distress over time. This study used an accelerated longitudinal design and multilevel modeling to examine a racially/ethnically diverse analytic sample of 231 LGBTQ adolescents aged 16-20 years at baseline, across six time points, and over 3.5 years. Results indicated that both psychological distress and victimization decreased across adolescence and into early adulthood. Furthermore, time-lagged analyses and mediation analyses suggested that distress was related to prior experiences of victimization, with greater victimization leading to greater distress. Support received from parents, peers, and significant others was negatively correlated with psychological distress in the cross-sectional model but did not reach significance in the time-lagged model. Analyses suggest that psychological distress might "get better" when adolescents encounter less victimization and adds to a growing literature indicating that early experiences of stress impact the mental health of LGBTQ youth. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Article
IntroductionThere is a paucity of systematic research in the area of non-suicidal self-injury (NSSI) in trans people.AimThe aim of this study was to investigate the prevalence of NSSI in trans people and the associations with intra- and interpersonal problems.Methods Participants were 155 untreated individuals with a diagnosis of transsexualism (according to International Classification of Disease-10 criteria) attending a national gender identity clinic.Main Outcome MeasuresAll participants completed the Self-Injury Questionnaire, the Symptom Checklist-90-Revised, the Rosenberg Self-Esteem Scale, the Hamburg Body Drawing Scale, the Experiences of Transphobia Scale, the Inventory of Interpersonal Problems-32, and the Multidimensional Scale of Perceived Social Support.ResultsThe sample consisted of 66.5% trans women and 33.5% trans men and 36.8% of them had a history of engaging in NSSI. The prevalence of NSSI was significantly higher in trans men (57.7%) compared with trans women (26.2%). Trans individuals with NSSI reported more psychological and interpersonal problems and perceived less social support compared with trans individuals without NSSI. Moreover, the probability of having experienced physical harassment related to being trans was highest in trans women with NSSI (compared with those without NSSI). The study found that with respect to psychological symptoms, trans women reported significantly more intrapersonal and interpersonal symptoms compared with trans men. Finally, the results of the regression analysis showed that the probability of engaging in NSSI by trans individuals was significantly positively related to a younger age, being trans male, and reporting more psychological symptoms.Conclusions The high levels of NSSI behavior and its association with interpersonal and interpersonal difficulties and lack of social support need to be taken into consideration when assessing trans individuals. The effect of cross-sex hormones and sex reassignment surgery on psychological functioning, including NSSI behavior, as part of the transitional journey of trans individuals should be explored in future studies. Claes L, Bouman WP, Witcomb G, Thurston M, Fernandez-Aranda F, and Arcelus J. Non-suicidal self-injury in trans people: Associations with psychological symptoms, victimization, interpersonal functioning, and perceived social support. J Sex Med **;**:**–**.
Article
Introduction: There is a paucity of research in the area of social support and psychological well-being among people with gender dysphoria. Aims: The present study aimed to investigate levels of social support among individuals with gender dysphoria compared with a matched control group. It also aimed to examine the relationship between social support and psychological well-being. Methods: Participants were 103 individuals diagnosed with gender dysphoria (according to ICD-10 criteria) attending a national gender identity clinic and an age- and gender-matched nonclinical control group recruited via social networking websites. Main outcome measures: All participants completed measures of social support (Multidimensional Scale of Perceived Social Support, MSPSS), psychopathology (Symptom Checklist 90 Revised, SCL), quality of life (Short Form 36 version 2, SF), and life satisfaction (Personal Wellbeing Index, PWI). Results: Trans women reported significantly lower MSPSS total and MSPSS family scores compared with control women, although these differences in levels of social support were no longer significant when SCL depression was controlled for. No significant differences were found between trans men and any other group. MSPSS scores did not significantly predict SCL subscales but did predict both SF subscales and PWI total scores. Conclusions: Trans women perceived themselves to be lacking social support. Given that social support is beneficial to quality of life and life satisfaction in those with gender dysphoria, this is of great concern. Though these findings have been derived from correlational results, extended research may highlight the value of clinicians helping trans women to seek out and maintain social support. Additionally, efforts could be made to educate and challenge attitudes of nontrans people towards those with gender dysphoria.
Article
This column reviews the evolution of lesbian, gay, bisexual, and transgender (LGBT) mental health advocacy in relation to modern mental health advocacy efforts. In addition to developments in organized psychiatry (e.g., American Psychiatric Association's LGBT caucus), grassroots LGBT community initiatives are playing an important role (e.g., Trevor Project providing crisis intervention/suicide prevention services to LGBT youth, face-to-face mental health services in LGBT community centers). Studies have found that LGBT individuals are at increased risk for mental health problems (e.g., depression, anxiety, substance misuse, suicidal ideation, self-harm). Mental health advocacy in the LGBT community has been slowed by the long-standing association of the concept of homosexuality with psychopathology in mainstream psychiatry (e.g., homosexuality was only removed from the DSM in 1973, ego dystonic homosexuality still appears in the ICD-10). However, positive developments in LGBT mental health advocacy have been fostered by the proposed minority stress model (i.e., that elevated risk of mental illness in LGBT individuals is a consequence of a hostile stressful environment). A particularly encouraging initiative is the It Gets Better Project, in which thousands of videos, some by prominent individuals, have been posted online to send a message of hope to LGBT youth facing harassment and low self-esteem. (Journal of Psychiatric Practice 2014;20:225-227.
Article
Adolescent transsexuals were compared with adolescent psychiatric out-patients and first-year university students to determine the extent to which other psychopathology is a necessary condition for the development of transsexualism. Three areas of psychological functioning associated with fundamental psychological disturbances—perceptual inaccuracy, disorders of thought and negative self-image—were assessed by means of the Rorschach Comprehensive System. The group of adolescent transsexuals was found to be intermediate between adolescent psychiatric patients and nonpatients for extent of perceptual inaccuracy. They did not differ significantly from nonpatients with regard to thinking disturbances and negative self-image. The psychiatric patients included significantly more individuals characterized by negative self image than the other groups. The results support the idea that mayor psychopathology is not required for the development of transsexualism. © 1997 John Wiley & Sons, Inc.
Article
To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients. Data gathered on 97 consecutive patients <21 years, with initial visits between January 1998 and February 2010, who fulfilled the following criteria: long-standing cross-gender behaviors, provided letters from current mental health professional, and parental support. Main descriptive measures included gender, age, Tanner stage, history of gender identity development, and psychiatric comorbidity. Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%). After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.
Article
The psychiatric impact of interpersonal abuse associated with an atypical presentation of gender was examined across the life course of 571 male-to-female (MTF) transgender persons from the New York City Metropolitan Area. Gender-related abuse (psychological and physical), suicidality, and Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) major depression were retrospectively measured across five stages of the life course using the Life Chart Interview. Among younger respondents (current age of 19-39), the impact of both types of abuse on major depression was extremely strong during adolescence and then markedly declined during later stages of life. Among older respondents (current age of 40-59), the impact of both types of abuse on major depression was strong during adolescence and then marginally declined during later stages of life. The effects of both types of abuse on suicidality were weaker but more consistently observed across the life course among both the younger and older respondents. Gender-related abuse is a major mental health problem among MTF transgender persons, particularly during adolescence. As these individuals mature, however, the consequences of this abuse appear less severe, which may represent the development of moderately effective mechanisms for coping with this abuse.
Article
To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes. We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random-effects meta-analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between-study heterogeneity not attributable to chance using the I(2) statistic. We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68-89%; 8 studies; I(2) = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56-94%; 7 studies; I(2) = 86%); 80% reported significant improvement in quality of life (95% CI = 72-88%; 16 studies; I(2) = 78%); and 72% reported significant improvement in sexual function (95% CI = 60-81%; 15 studies; I(2) = 78%). Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.
Article
Suicide ranks as the third leading cause of death for adolescents. Recent data from the Centers for Disease Control and Prevention (CDC) indicate that the adolescent suicide rate increased 18% between 2003 and 2004. Sport may represent a promising protective factor against adolescent suicide. This study examined the relative risk of hopelessness and suicidality associated with physical activity and sport participation. Data from the CDC's 2005 Youth Risk Behavior Survey were analyzed. Logistic regression modeling was used to compare the odds of hopelessness and suicidality in students who engaged in various levels of physical activity to inactive students. Similar analyses were performed comparing risks of athletes to nonathletes, and the risks of highly involved athletes to nonathletes. Findings showed that frequent, vigorous activity reduced the risk of hopelessness and suicidality among male adolescents. However, low levels of activity actually increased the risk of feeling hopeless among young females. Yet, for both males and females, sport participation protected against hopelessness and suicidality. These findings indicate that involvement in sport confers unique psychosocial benefits that protect adolescents against suicidality. Findings suggest that mechanisms other than physical activity contribute to the protective association between sport and reduced suicidality. Social support and integration may account for some of the differences found in suicidality between athletes and nonathletes.
Article
Since the first sex-reassignment operation in Denmark at the Rigshospitalet in 1951, a total of 37 patients, 29 males and 8 females, have had sex-modifying surgery and a change in legal status. In our experience a basic insecure gender identity is a predominant trait in transsexuals, dating back to earliest childhood. This insecurity and a concomitant anxiety are overcome differently by the two transsexual sexes. In male transsexualism, the most outstanding characteristic is a narcissistic withdrawal to a condition marked by submission and pseudofeminity. Anxiety and insecurity are basic to the gender dysphoria but are subdued by means of fantasy escape and gratification in aestheticized ego-ideals with suppression of aggressive and sexual feelings. This results in the often observed pseudofeminity in the male transsexual. A core group of transsexual males are marked by a persistent pseudofeminine narcissism. They have stable ego strength, are agenital in sexual attitude, and have an intact sense of reality. This group is expected to remain so after sex reassignment. The transsexual female assumes a narcissistic, phallic attitude displaying outer activities and caricatured masculine manners in an attempt to subdue her insecurity. Examples are given of the characteristic splitting of these persons' phenomenological ego-experiences and how different their reality testing is from that of psychotic persons with a desire for sex change. Transsexual females are much more sexually active than transsexual males. We find a closer connection between female homosexuality and transsexualism than between male homosexuality and transsexualism.