Beyond Male and Female: Poststructuralism and the Spectrum of Gender

ABSTRACT

Transgender explodes the notion that male and female are discrete categories. Transgender people change sex or inhabit third (or multiple) sex, androgynous, or fluid identities. I theorize this by developing and then critiquing poststructuralist transgender theory. A poststructuralist theory of transgender disassociates sex and gender, models both as constructed, and emphasizes the technologisation and commodification of the body. Poststructuralist accounts can, however, entail denial of bodily limitations, erase transgender people's subjective experience, and overlook social and political factors, such as the importance of gender categories as a basis for identity politics. I argue for the deconstruction of gender binaries to be combined with the development of a gender-pluralist, flexible, model of gender. This points to the replacement of bipolar models of gender with a gender spectrum, with important implications for conceptualizing gender. My analysis is based on empirical research with a range of transgender people.     

Investigating the social integration and wellbeing of transgender individuals: A meta-synthesis

Introduction: There is growing literature about the experiences of social integration and wellbeing of transgender individuals. However, there has been no synthesis across this body of research. Accordingly, the aim of this review was to aggregate, interpret, and synthesize findings from qualitative studies pertaining to the social integration and wellbeing of transgender individuals.

Methods: This study synthesized findings from 18 qualitative and mixed method studies which had explored the social integration and wellbeing of transgender individuals, using Noblit and Hare's meta-ethnography method. The Critical Appraisal Skills Programme was also used to appraise the 18 included studies.

Results: Data from the included 18 individual studies ranged from moderate to strong in quality. Data analysis revealed five major themes which influenced transgender individuals' daily lives. These were gender transition and disclosing gender identity, health and self-isolation, living with stigma and discrimination: health care, leisure and work, the importance of relationships, and last, overcoming adversity: stories of what can work.

Conclusion: This meta-synthesis reinforces many preconceived notions about transgender individuals. These include being at high risk of social exclusion, experiencing discrimination and stigma across many social situations, and last, being at high risk of poor wellbeing. This study also found that there is further need for studies that investigate the self-isolation of transgender individuals as well as this group's relationship and experiences with health care professionals and providers.     

Transgender and anxiety: A comparative study between transgender people and the general population

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.     

Discussing transgender topics within gay-straight alliances: Factors that could promote more frequent conversations

ABSTRACT

Background: Gay-straight alliances (GSAs) have potential to facilitate conversations on transgender and gender-diversity issues among members. We examined how frequently GSA members discussed transgender and gender-diversity topics within GSAs, whether GSAs varied from one another in the extent to which these conversations occurred, and identified factors that distinguished which members and GSAs discussed such topics more often than others.

Methods: Participants were 295 members of 33 high school GSAs in the state of Massachusetts who completed surveys that assessed their experiences within their GSA.

Results: On average, youth discussed transgender and gender-diversity issues with some regularity, but this varied significantly across GSAs and among youth within each GSA. Youth who had transgender friends, perceived a more respectful GSA climate, and accessed more information/resources and engaged in more advocacy within the GSA reported more frequently discussing transgender and gender-diversity issues. Also, GSAs with transgender members, whose members collectively perceived a more respectful climate, accessed more information/resources and did more advocacy, and who reported lower socializing or support discussed transgender and gender-diversity issues more frequently than other GSAs.

Conclusions: This information could inform GSA programming to facilitate more transgender and gender-diversity topic discussions and ensure that members feel encouraged to participate in them.     

Care of the transgender or gender-nonconforming patient undergoing in vitro fertilization

Background: Assisted reproductive technologies, including in vitro fertilization (IVF), can be utilized for fertility preservation and family building in the transgender and gender-nonconforming population.

Methods: This is a retrospective case series from an academic tertiary care center.

Results: We present three couples with a transgender or gender-nonconforming member who pursued IVF to build their families. The first case involves a transgender man who suspends hormone therapy to undergo IVF. The second involves a transgender woman who uses her previously banked sperm to undergo IVF with her wife. The third involves a gender nonbinary patient and their cisgender wife who create and transfer embryos from both partners.

Conclusion: IVF can provide unique family-building opportunities to transgender and gender-nonconforming patients, and providers should seek to broaden their clinical experience with this population.     

Sex,gender, and intersex: anthropological,medical, and ethical critiques and proposals

ABSTRACT

The problems of intersex have received little attention from both Catholic Magisterium and theologians. Early in 2019, the Vatican Congregation for Catholic Education issued a document intended to be a pathway for a dialogue on the issue of gender in education. This essay responds to that document as a contribution to filling theological gaps in the consideration of intersex. It first explains and critiques the theological anthropology underlying the Vatican document and then analyzes and critiques Western cultural, medical approaches to intersex persons. It dialogues with the experience of intersex persons and the social sciences that document it and concludes by proposing ethical principles to guide intersex persons, their parents, and their physicians in the care and treatment of intersex.     

Seeking help when transgender: Exploring the difference in mental and physical health seeking behaviors between transgender and cisgender individuals in Ireland

Abstract

Background: While there is growing awareness of the need to support the physical and mental wellbeing of transgender people, some may be reluctant to seek help from healthcare professionals. Little is understood about the mechanisms that influence help-seeking behavior in this group.

Aims: This study aimed to compare transgender and cisgender participants in their likelihood to seek help for both physical and mental health conditions, and to explore whether this help-seeking behavior is predicted by a range of sociodemographic and psychological variables.

Methods: 123 participants living in Ireland (cisgender= 67; transgender= 56) completed a questionnaire which included demographic questions, as well as measures of optimism (LOT-R), self-esteem (RSES), psychological distress (GHQ-12), attitudes towards seeking psychological help (ATSPPH-SF), and attitudes towards seeking help for a physical health problem (Attitudes Towards Seeking Medical Help Scale- Action/Intervention subscale). Associations between predictor variables and mental and physical health seeking were explored using correlation analysis and stepwise regressions.

Results: Transgender participants were less likely to seek help for a physical health issue than cisgender participants, but did not differ in mental health help-seeking behaviors. Results suggest that this may be due to differences in optimism, self-esteem and psychological distress. Transgender participants had significantly lower optimism and self-esteem, which were two factors linked to poorer physical health seeking behaviors. Optimism also emerged as a significant predictor in mental health seeking behaviors.

Discussion: The lack of a significant difference for mental health help-seeking between the transgender and cisgender participants is encouraging, as it suggests that there is less stigma surrounding mental illness than expected, however findings also contradict previous findings suggesting that physical health is less stigmatized. This could be due to stigma relating to gender-specific healthcare and suggests that healthcare professionals should acknowledge the specific healthcare needs and concerns among transgender individuals.     

Prevalence of anxiety symptoms and disorders in the transgender population: A systematic review of the literature

Introduction: Anxiety disorders are the most common mental illness in the general population, affecting 18% of the population in the United States (12 months prevalence) and 13.6% in Europe (life time prevalence). Several studies have also described high rates of anxiety disorders and symptoms of anxiety among the transgender population. There is, however, a great variation of results (particularly related to gender prevalence), and few studies have described the type of anxiety disorders specific to the transgender population.

Aim: To collect and critically appraise the information from the available studies describing prevalence rates of anxiety disorders and symptoms.

Results: A total of 25 cross-sectional (n = 17) and longitudinal (n = 8) studies were found. Cross-sectional studies described higher prevalence rates of anxiety symptoms in the transgender group than in the cis population. The prevalence of anxiety disorders range from 17% to 68%. The most common anxiety disorders found were specific phobias, social phobias, panic disorders, and obsessive-compulsive disorders. Most of the large studies suggest higher levels of anxiety symptoms and disorders in transgender men compared with transgender women; however, considerable variation in results was found.

Conclusions: The findings identified that there is considerable variation in anxiety disorders and symptoms among transgender people attending transgender health services. These findings are likely to be the result of the tools used, the lack of matching controls, and the lack of homogeneity of the group studied. Overall this review indicates high levels of anxiety symptoms and disorders among transgender people attending gender services, primarily (but not exclusively) before commencement of cross-sex hormone treatment. Anxiety disorders related to social interaction (such as social anxiety) and panic attack appear to be particularly common, however more rigorous studies to confirm those findings are needed.     

Are Transgender Persons at Higher Risk for HIV Than Other Sexual Minorities? A Comparison of HIV Prevalence and Risks

SUMMARY

Recent studies have shown that transgender people are at high risk for HIV. Few studies, however, have directly compared the HIV risks and sexual health of transgender persons with that of other sexual minority populations. This study used baseline data of intervention studies targeting transgender persons, men who have sex with men, and women who have sex with women and men to compare their HIV risk behavior and sexual health. No significant differences were found between transgender persons and nontransgender men or women in consistent condom use or attitudes toward condom use. Transgender persons were less likely to have multiple partners and more likely to be monogamous than men who have sex with men; no differences were found between transgender persons and the women in this respect. When combining data on condom use, monogamy, and multiple partners, transgender persons did not differ from either nontransgender group in their overall risk for HIV. Transgender persons were less likely than the men or the women to have been tested for HIV. With regard to HIV prevalence, 17% of the men compared to only one transgender person and none of the women reported being HIV-positive. Transgender persons were also less likely than men who have sex with men to use drugs; no differences were found in the use of alcohol. However, with regard to mental health, transgender persons were more likely than the men to have experienced depression and more likely than men or women to have considered or attempted suicide. Finally, transgender persons reported the lowest levels of support from family and peers. Thus, in our sample, transgender persons appear to be at lower risk for HIV but at higher risk for mental health concerns than men who have sex with men. Remarkably few differences were found between transgender persons and women who have sex with women and men-a finding which might reflect the impact of social stigma on sexual health and have implications for the design of future HIV/STI prevention efforts.     

Transactional pathways of transgender identity development in transgender and gender-nonconforming youth and caregiver perspectives from the Trans Youth Family Study

Background: A growing body of research has examined transgender identity development, but no studies have investigated developmental pathways as a transactional process between youth and caregivers, incorporating perspectives from multiple family members. The aim of this study was to conceptualize pathways of transgender identity development using narratives from both transgender and gender-nonconforming (TGN) youth and their cisgender (nontransgender) caregivers.

Methods: The sample included 16 families, with 16 TGN youth, ages 7 to 18 years, and 29 cisgender caregivers (N = 45 family members). TGN youth represented multiple gender identities, including trans boy (n = 9), trans girl (n = 5), gender-fluid boy (n = 1), and girlish boy (n = 1). Caregivers included mothers (n = 17), fathers (n = 11), and one grandmother. Participants were recruited from LGBTQ community organizations and support networks for families with transgender youth in the Midwest, Northeast, and South regions of the United States. Each family member completed a one-time, in-person semistructured qualitative interview that included questions about transgender identity development.

Results: Analyses revealed seven overarching themes of transgender identity development, which were organized into a conceptual model: Trans identity development, sociocultural influences/societal discourse, biological influences, family adjustment/impact, stigma/cisnormativity, support/resources, and gender affirmation/actualization.

Conclusions: Findings underscore the importance of assessing developmental processes among TGN youth as transactional, impacting both youth and their caregivers.     

The Gender Congruence and Life Satisfaction Scale (GCLS): Development and validation of a scale to measure outcomes from transgender health services

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.     

Ethical,Legal, and Psychosocial Issues in Care of Transgender Adolescents

SUMMARY

Complete care for transgender adolescents must be considered in the context of a holistic approach that includes comprehensive primary care as well as cultural, economic, psychosocial, sexual, and spiritual influences on health. Not all transgender adolescents have gender dysphoria or wish to undergo sex reassignment. In this article we focus on general care of transgender adolescents by the non-specialist working in primary care, family services, schools, child welfare, mental health, and other community settings.     

Crossing borders and demolishing boundaries: the connected history of the Israeli transgender community 1953–1986

ABSTRACT

This is the first study to examine the early history of the Israeli transgender community. It covers three decades of transgender activity, from Rina Nathan’s public campaign in the 1950s to permit gender confirmation surgeries in the country to the decision in 1986 to allow surgeries in one public hospital after a lengthy vetting process that de facto held up or disqualified the great majority of applications. The main focus of this study is the generation of “founding mothers” of the transgender community in the 1960s and 1970s and their quest to obtain knowledge, medical technology and paperwork necessary for their gender journeys. We argue that decades before the creation of the internet, Israeli trans pioneers crossed domestic and international boundaries (both social and spatial) and created a network, which later generations of transgender women and men would depend on. This article relies on oral history, contemporaneous media reports and archival documents.     

Exploring rates of transgender individuals and mental health concerns in an online sample

Background: Prevalence estimates of adults identifying as transgender are scarce, particularly in the United States. Method: The current study endeavored to estimate the prevalence of individuals identifying as transgender in a large online sample of adult U.S. residents (n = 6,727) and compare the prevalence of common mental health disorders (depression, anxiety, attention-deficit/hyperactivity disorder) and the age of onset for individuals identifying as men or women versus those identifying as transgender. Results: The prevalence estimate of individuals identifying as transgender was 0.8%. Individuals identifying as transgender were significantly more likely than individuals identifying as men or women to report having had a single diagnosis or co-occurring diagnoses for all three disorders examined. Additionally, transgender individuals were more likely than individuals identifying as men or women to receive a diagnosis of anxiety or depression at a younger age. Conclusion: Given the prevalence of transgender individuals and the associations with common mental health conditions, clinicians must be informed and competent to care for their clinical needs. This study introduces online crowdsourcing resources as a potentially fruitful option for reaching and researching gender diversity.     

Mental health and quality of life in non-binary transgender adults: a case control study

Abstract

Background: The social challenges that non-binary people experience, due in part to social intolerance and the lack of validation of non-binary gender identities, may affect the mental health and quality of life of this population. However, studies that have distinguished between non-binary and binary transgender identities are lacking.

Aim: To compare the mental health and quality of life of a community sample of non-binary transgender adults with controls (binary transgender people and cisgender people) matched on sex assigned at birth.

Method: A total of 526 participants were included. Ninety-seven were classified as non-binary and were compared with two control groups: 91 people classified as binary and 338 cisgender people. Only transgender people not on gender affirming hormone treatment or who had not undergone gender affirming surgery were included. Participants were invited to complete an online survey that included mental health and quality of life measures.

Results: Non-binary people reported significantly better mental health than binary transgender people, but worse than cisgender people. Overall, there were no significant differences in quality of life between non-binary and binary transgender participants assigned male at birth and transgender females, but non-binary assigned males at birth had better scores on the psychological and social domains of quality of life than transgender males. Quality of life was better across all domains in cisgender people than transgender groups.

Conclusion: There is an inequality with regard to mental health and quality of life between non-binary (and binary) transgender people and the cisgender population that needs to be addressed. The better mental health scores in non-binary people may reflect lower levels of body dissatisfaction among the non-binary population. Mental health problems and poor quality of life are likely to have social causes and hence legislative measures and broader government-led inclusive directives should be put in place to recognize and to validate non-binary identifying people.     

“I love you as both and I love you as neither”: Romantic partners’ affirmations of nonbinary trans individuals

Abstract

Background: Transgender microaffirmations are subtle endorsements of a person’s gender identity through both verbal acknowledgements and behavioral gestures. Microaffirmations positively impact individuals who identify as transgender by acknowledging their gender identity and by communicating a sense of support and validation.

Aims: This study focuses on microaffirmations specifically directed toward nonbinary transgender individuals within romantic relationships.

Methods: Participants included 161 adults who identified as nonbinary: 85 who identified as gender nonconforming and 76 who identified as agender. These participants were either currently in a romantic relationship or had been in a romantic relationship within the past 5 years. Participants completed an online survey and provided examples of the microaffirmations they experienced from their romantic partners.

Results: Responses were analyzed via thematic analysis, resulting in four overarching themes: (1) Identity Validations, acknowledgement and acceptance of nonbinary identity; (2) Identity Endorsements, active endorsements of nonbinary through language or behavior; (3) Active Learning, self-education about nonbinary identities; and (4) Active Defense, interruptions of others’ negative actions directed at nonbinary partners.

Discussion: Discussion of the results focuses on understanding how microaffirmations operate to complicate binary notions of gender/sex and positively influence nonbinary transgender individuals in interpersonal relationships.     

Internalized transphobia and mental health among transgender adults: A nationwide cross-sectional survey in South Korea

Abstract

Introduction: Transgender people are stigmatized in South Korea (hereafter Korea), where cultural expectations of a biologically-based, binary sex and gender system present fundamental challenges to those whose gender identity does not align with their birth-assigned sex. A growing international body of literature implicates gender minority stress as a key contributor to transgender mental health disparities, but little research has been conducted on this topic in Korea. As in other cultural settings, depression and suicidality are urgent public health concerns for transgender people in Korea, primarily for those who have not initiated gender affirming medical treatment (GAMT), such as cross-sex hormone therapy. In the current study, an international and interdisciplinary team of authors apply the lens of gender minority stress to elucidate the relationships between a key facet of gender minority stress, internalized transphobia (ITP), and outcomes of depressive symptoms and suicidality.

Methods: Based on a cross-sectional survey of 207 Korean transgender adults, the current study evaluates the relationships between ITP and depressive symptoms, suicidal ideation, and suicide attempts. ITP was measured with an eight-item, Korean-language questionnaire adapted from the Gender Minority Stress and Resilience Measure through a translation and back-translation process.

Results: Korean trans women and trans men mean (mean age?=?26.4) were included in the analysis, most of whom had at least one experience of any GAMT. The findings of this study show that Korean transgender adults face similar public health concerns such as high prevalence of depressive symptoms, suicidal ideation, and suicide attempts. As predicted, ITP was significantly related to depressive symptoms, suicidal ideation, and suicide attempts.

Conclusion: The authors suggest potential clinical, policy, and research applications, including institutional interventions, to address structural and cultural barriers to optimal mental health and GAMT as well as mental health interventions to reduce Korean transgender people’s internalized negative beliefs about their gender identity.