“I knew that I wasn’t cis,I knew that,but I didn’t know exactly”: Gender identity development,expression and affirmation in youth who access gender affirming medical care

Abstract

Background: Research about gender identity development is still in its infancy, especially among youth who experience gender dysphoria and are accessing gender-affirming medical care.

Aims: This article contributes to the literature on how gender identity and gender dysphoria is experienced, expressed and addressed by youth who have started, or are just about to start, a gender-affirming medical intervention.

Methods: The project draws from qualitative interviews with 36 trans children and youth of different ages and stages of puberty. The data were collected in three specialized Canadian clinics that offer gender-affirming care and they were analyzed through inductive thematic analysis.

Results: Two interlinked dimensions of the youth’s lives allow meaning-making of their gender identity: 1) internal or personal and 2) interactional or social processes. Careful analysis reveals three gender identity development pathways that may be taken by youth, from early questioning to the affirmation of their gender identity. A discussion of current models of gender identity development and their limitations concludes the article.     

Non-binary youth: Access to gender-affirming primary health care

ABSTRACT

Background: Transgender (trans) youth who identify outside the gender binary are a growing subpopulation. In this article, we document differences in access to gender-affirming health care between binary and non-binary identified trans youth and explore ways of meeting the health needs of non-binary youth within primary care settings.

Methods: The Canadian Trans Youth Health Survey is a national online survey of trans youth, 14–25 years, conducted in 2013–2014. Among the 839 participants who responded to gender identity items in the survey, 41% identified as non-binary. We compared demographic, health outcome, and health care access responses between non-binary and binary (trans girls/women and trans boys/men) youth.

Results: Non-binary and binary youth were similar in most demographics, including age, geographic distribution, and ethnocultural backgrounds, however a larger proportion (82%) of non-binary youth were assigned female at birth. Older non-binary youth (aged 19–25) were significantly more likely to forego needed healthcare than older binary youth; no significant differences were found between younger (14–18) non-binary and binary youth in foregoing healthcare. Overall, non-binary youth (13%) were significantly less likely than binary youth (52%) to access hormone therapy, but they were more likely than binary youth to report experiencing barriers to accessing hormone therapy when needed.

Conclusions: Non-binary trans youth in Canada report challenges in accessing needed gender-affirming healthcare. Primary care providers are well-situated to integrate a broad range of gender-affirming care services into practice in order to address the unique needs of non-binary youth. Future research is warranted to explore experiences of non-binary youth related to barriers to care and to explore how services can be designed and delivered to better meet the needs of non-binary youth seeking gender-affirming primary care.     

Experiences of surgery readiness assessments in British Columbia

Abstract

Background: A surgical readiness assessment is a major step in the medical journey of trans people seeking gender-affirming surgery. Much of the peer-reviewed literature surrounding surgical readiness assessments emphasizes the perspectives of academics and clinicians, leaving the voices of trans and gender diverse patients largely unheard.

Aims: This paper foregrounds patient experiences with surgery readiness assessments to discuss the tensions, challenges and opportunities they generate.

Methods: We conducted a thematic analysis of 35 in-depth interviews with trans people who accessed or were seeking to access gender-affirming surgery in British Columbia.

Results: We developed three main themes to capture participants’ narratives of their surgical assessment experiences. The first, assessments as gatekeeping, explores the stories of people who described their assessments as outdated and even discriminatory processes. The second, assessments as a barrier to care, discusses the informational missteps, bureaucratic regulations, economic issues, and geographic concerns that made assessments difficult to access. The third, assessments as useful, includes positive stories about assessments that often involved feeling supported by an assessor and feeling prepared for the next steps.

Discussion: These narratives demonstrate how much variation exists among people’s experiences of readiness assessments for gender-affirming surgery. No matter how their actual assessment turned out, many participants approached their appointments with a great deal of anxiety and trepidation. We attributed this stress was to challenges ranging from lengthy wait times, arbitrary medical gatekeeping, a lack of access to knowledgeable and supportive providers, unclear or changing administrative processes, and insufficient communication. To address these challenges, it is crucial for the medical system to create more accessible pathways with centralized, up-to-date information for people trying to access assessments. Patients are best served by multi-disciplinary gender-affirming teams that provide individualized care.     

Bullies,blades, and barricades: Practical considerations for working with adolescents expressing concerns regarding gender and identity

ABSTRACT

Background: Adolescents, by their very nature and need for maturity, struggle with issues of the self and identity, while challenging the very systems that are there to support them. However, gender diverse adolescents may become detached and overwhelmed as a trans identity solidifies during this time. Bullies, blades and barricades describes the challenges, hardship and dispossession that some gender diverse adolescents face from interpersonal and intrapersonal conflicts, societal pressure and hostility.

Method: This paper utilizes the current research on safety and risks affecting trans youth, the authors clinical experience of trans and gender diverse adolescents, and recommendations in the literature for professional care and support of gender diverse adolescents to identify the various ways gender diverse adolescents are negatively affected by their experiences.

Results: Bullying is not limited to school or peer environments and may be present in adolescents' homes, in local communities, in professional services or from sources of information such as the media. The physical dangers gender diverse adolescents face may arise from victimization, violence or rejection, or self-harming behaviors due to negative beliefs, fear or frustration. Barriers preventing disclosure and expression of gender and/or identity may stem from negative experiences, rejection, pubertal changes, imposed limitations, dependence upon school, home or legal environments, or other spheres of influence.

Discussion: Affirmative approaches, individual focus, recognition of family dynamics, inclusion of significant others, advocacy in school and local community environments as well as professional training are the most commonly recommended interventions. This paper provides an inclusive review of the myriad of challenges confronting gender diverse adolescents including often unrecognized forms of pressure, oppression and restrictions. This paper aims to support clinicians by contextualizing the adversity that gender diverse adolescents face and offers strategies for engagement and intervention.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

Health disparities between binary and non binary trans people: A community-driven survey

Abstract

Background: Genderqueer and nonbinary () people have remained largely invisible in health research. Previous research shows worse outcomes on health indicators for trans people when compared with cisgender controls, but the differences between binary trans and GQNB individuals are inconclusive.

Aims: To compare overall health and well-being of GQNB people with controls of trans men and trans women, taking into account the impact of the additive effect of their socio-economic position, as well as their current need for gender affirming medical interventions.

Methods: A community-driven survey was conducted in 2016 in five countries (Georgia, Poland, Serbia, Spain, and Sweden). Self-reported health and general well-being were analysed for differences between binary trans and GQNB respondents. The effects of multiple control variables (age, economic situation, educational level, belonging to an ethnic, religious, sexual or ability minority group, sex assigned at birth) as well as the current need for gender affirming medical interventions were controlled for.

Results: The sample consisted of 853 respondents aged 16 and older, with 254 trans women (29.8%), 369 trans men (43.2%), and 230 GQNB people (26%). GQNB respondents showed significantly worse self-reported health and worse general well-being in comparison to binary trans respondents. Additional negative impacts of having a lower educational level, having more economic stress, and belonging to a disability minority group were found. Being in need of gender affirming medical interventions contributed significantly to worse self-reported health, whereas being younger contributed to worse general well-being.

Discussion: In understanding health disparities between binary trans and GQNB people, it is necessary to take into account the additive effect of multiple socio-economic positions, and the current need for gender affirming medical interventions. The high proportion of GQNB respondents who report worse health outcomes highlights the need for policy makers and health-care providers in creating nonbinary-inclusive environments.     

Digging beneath the surface: Results from stage one of a qualitative analysis of factors influencing the well-being of trans youth in Quebec

ABSTRACT

Background: The literature on trans youth has been dominated by etiological studies interested in trans experience as a medical phenomenon. An emerging body of literature has begun to document that trans youth are a diverse, vulnerable, yet resilient population, and to investigate the role of various sites of support such as the family, peer groups, institutions, and community spaces in contributing to or impeding trans youth's well-being.

Method: This article presents the results of Stage One of interviews (n = 24) conducted for a Community-Based Participatory Action Research (CBPAR) qualitative research project based in Quebec. It studies the factors that enhance trans youth's well-being as well as the factors of oppression that negatively affect it. This paper offers a brief overview of the anti-oppressive methodology used for this project, emphasizing how CBPAR was combined with Grounded Theory (GT) methods to encourage the direct involvement of communities and the translation of knowledge into action.

Results: We present preliminary categories emerging through the ongoing axial coding process. These categories address trans youth's experiences in and perceptions of various “sites”: 1) healthcare services both for gender-related and general care, 2) other institutional spaces, 3) the family and other social circles, and 4) community spaces.

Conclusion: While much of this study's results support existing evidence on trans youth's experiences, they also provide a more nuanced portrayal of the complex ways in which recognition, as well as non-, mis-, or mal-recognition, influence trans youth's well-being at different sites. We also argue that recognition itself must be considered through the lens of intersectionality.     

Expanding the evidence: Developments and innovations in clinical practice,training and competency within voice and communication therapy for trans and gender diverse people

Background: Speech and language therapists (SLTs) deliver voice and communication therapy for trans and gender diverse people to facilitate authentic vocal and communicative expression. Davies, Papp, and Antoni (2015) have provided a comprehensive review of the literature, with recommendations for good clinical care. Several areas highlighted as gaps in the research were identified by the current authors as ones in which evidence is expanding.

Aims: To demonstrate 1) an expansion of the evidence base in particular innovations in voice group therapy for trans women and trans men; 2) the importance of delivering voice and communication therapy as part of a complete approach to trans and gender diverse health care; and (3) developments in training and competency in the UK.

Method: Data were drawn from three small-scale projects, two surveys, and one audit.

Measurements: Data from survey and audits and pre- and post-group acoustic measures of and client self-perceptual measures, including the Transsexual Voice Questionnaire (TVQ^MtF); a client-generated set of questions for trans men; and the migration of vocal identity map, adapted from Narrative Therapy practices.

Results: Positive outcomes for both pitch measures and client perception were recorded. Audit and survey data provided evidence of developments in training and competency in the UK.

Conclusion: Evidence supports group therapy as a successful approach for trans individuals across a number of parameters of voice and self-perception. Voice group protocols for both trans men and trans women should take account of the social context within which to explore relational presence and authentic voice. SLTs within gender identity clinics provide voice and communication as part of a broader pathway of care, alongside sharing professional knowledge and skills. Current UK developments are documented as indicators of positive responses to the growth in the number of SLTs seeking to develop specialist skills within this field.     

I'm more driven now: Resilience and resistance among transgender and gender expansive youth and young adults experiencing homelessness

ABSTRACT

Background: Little is known about the resilience strategies of transgender and gender expansive youth and young adults (YYA) experiencing homelessness. In addition to difficulties accessing trans-affirming supports and services, transgender and gender expansive YYA must contend with structural constraints and oppressive messages about who they are and who they can become. Despite these challenges, transgender and gender expansive YYA experiencing homelessness are finding innovative ways to resist the multiple and overlapping institutionalized challenges they face.

Methods: This qualitative study examined the ways a group of transgender and gender expansive YYA demonstrate resilience and resist dominant narratives about what it means to be young, transgender and experiencing homelessness.

Results: Two primary themes were identified through which transgender and gender expansive YYA experiencing homelessness demonstrated resilience in the midst of structural constraints and oppressive narratives about who they are and who they can become: personal agency and future orientation. Participants exercised personal agency through self-definition and making their own choices. They oriented themselves to future possibilities through positive meaning-making and re-visioning the meaning of home. Participants engaged in these acts of resilience and resistance despite receiving negative messages about themselves.

Conclusions: Study findings illustrate the capacity of transgender and gender expansive YYA experiencing homelessness to reframe their challenges as positive experiences, integral to the people they have become or will be in the future. Findings point to the need to expand conceptualizations about people experiencing homelessness, and to utilize a strengths-based framework in practice and research.     

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.     

Disrupting the trans-versus-Catholic dichotomy: An example from a Canadian elementary school policy

ABSTRACT

Background: Mainstream media is increasingly reporting on the relationships between Catholic and trans identities in parochial schools, particularly with regard to gendered washroom use. With greater numbers of trans youth coming out at younger ages, significant educational policy changes are being considered around how Catholic schools can or should include trans youth.

Method: This study applies trans and queer theologies to Critical Discourse Analysis (CDA) in investigating the Wilson case, which was the first known instance of a Catholic school including some affirming policy provisions for trans youth. The authors additionally collected and coded 12 news articles from a variety of platforms to discern and discuss the theological arguments in the public square against more fulsome trans student inclusion in Catholic schools.

Results: The authors found two related theological arguments against full inclusion, namely the notion that (1) Gender is God-given and therefore cannot be chosen or changed, and (2) That transgressive bodies are not sacred parts of the divine gender plan.

Conclusion: Trans theology allowed the authors to disrupt both of the theological claims advanced by the Catholic educators quoted in the Wilson case. This created rich, imaginative space in which to reconsider the relationships between Catholic and trans identities, namely by not arranging them in a binary. Significance for policy-making in parochial schools is discussed.     

It’s my safe space: The life-saving role of the internet in the lives of transgender and gender diverse youth

Abstract

Background: Public awareness of Transgender and Gender Diverse (TGD) identities has grown significantly; however, acceptance and support remain elusive for many TGD youth. Resultant experiences of marginalization and stigmatization contribute to elevated rates of psychological distress and suicidality among TGD youth. Emergent evidence suggests that the internet may offer TGD youth safety, support, and community previously unavailable.

Aim: The primary aim of this qualitative inquiry is to engage in an in-depth exploration of the online experiences and processes which help protect against psychological distress and promote well-being among TGD youth.

Methods: Data were culled from a mixed-methods, online study of sexual and gender minority youth from across the United States and Canada which followed Institutional Review Board approved protocols. Participants for this study represent a sample (n?=?260) of TGD participants aged 14–22 (x? = 17.30). Data were analyzed using Charmaz’ grounded theory strategies.

Results: Data revealed that the internet offers TGD youth affirming spaces that, for the most part, do not exist in their offline lives. Online, TGD youth were able to engage meaningfully with others as their authentic selves, often for the first time. These experiences fostered well-being, healing, and growth through five processes: 1. Finding an escape from stigma and violence, 2. Experiencing belonging, 3. Building confidence, 4. Feeling hope, and 5. Giving back.

Discussion: The unique and innovative ways in which participants use online spaces to foster resilience offer important insights to inform affirmative practices with TGD young people.     

What about the family in youth gender diversity? A literature review

Abstract

Background: Previous research has suggested that gender diversity affects everyone in the family, with positive mental health and global outcomes for gender diverse youth reliant on receiving adequate family support and validation. Although the individual mental health, treatment and outcomes for gender diverse youth have received recent research attention, much less is known about a family perspective. Hence, a review of the literature exploring youth gender diversity from a family perspective is warranted.

Aims: To systematically identify, appraise and summarize all published literature primarily exploring gender diversity in young people under the age of 18?years, as well as selected literature pertaining to a family understanding.

Methods: Six electronic databases (CINAHL, MEDLINE, EMBASE, PsycINFO, SCOPUS, Web of Science) were searched for relevant literature pertaining to youth under the age of 18?years.

Results: Research evidence was consistently found to support the beneficial effects of a supportive family system for youth experiencing gender diversity, and a systemic understanding and approach for professionals. Conversely, lack of family support was found to lead to poorer mental health and adverse life outcomes. Few articles explored the experience of siblings under the age of 18?years.

Discussion: This literature review is the first to critically evaluate and summarize all published studies which adopted a family understanding of youth gender diversity. The review highlighted a lack of current research and the need for further targeted research, which utilizes a systemic clinical approach to guide support for gender diverse youth and family members.     

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 affirmative lifespan approach (GALA): A framework for competent clinical care with nonbinary clients

Abstract

Background: The limited research on nonbinary individuals suggests that this community experiences significant health disparities. Compared to binary transgender individuals, research suggests that nonbinary individuals are at elevated risk for discrimination and negative mental health outcomes, including depression, anxiety, traumatic stress, and suicidality. Even mental health providers who work with binary transgender individuals often lack knowledge of and training to work competently with nonbinary individuals.

Methods: The authors of this conceptual article present the Gender Affirmative Lifespan Approach (GALA), a psychotherapy framework based in health disparities theory and research, which asserts that therapeutic interventions combating internalized oppression have the potential to improve mental health symptomatology resulting in improved overall health and well-being for gender diverse clients. GALA’s therapeutic interventions are designed to promote positive gender identity development through five core components: (1) building resiliency; (2) developing gender literacy; (3) moving beyond the binary; 4) promoting positive sexuality; and (5) facilitating empowering connections to medical interventions (if desired).

Results: The core components of the GALA model are individualized to each client’s unique needs, while taking into consideration age and acknowledging developmental shifts in, or fluidity of, gender across the lifespan. This model represents an inclusive, trans-affirmative approach to competent clinical care with nonbinary individuals.

Discussion: Application of the GALA model with nonbinary clients is discussed, including one clinical case vignette.     

Transgender and gender non-conforming adult preparedness for aging: Concerns for aging,and familiarity with and engagement in planning behaviors

Abstract

Background: Research on transgender and gender-nonconforming (TGNC) aging is limited. To date, most of the literature about TGNC aging has focused on discrimination (particularly in healthcare), violence and abuse, caregiving and family relations, and religiosity.

Aims: The purposes of this study were to: (a) document concerns about aging among TGNC adults, including concerns that are identity-specific; (b) examine preparation for aging and end of life (i.e., familiarity and planning) among TGNC adults; and (c) examine potential differences in familiarity and planning based on gender identity.

Methods: One hundred fifty-four individuals who currently or have ever identified as TGNC completed a national online survey assessing these constructs.

Results: TGNC individuals reported many concerns about aging, both gender identity-specific and not. The most common aging concern was losing the ability to care for themselves followed by having to go into a nursing home or assisted living facility. The age preparatory behaviors individuals were most commonly aware of included: life insurance, wills, organ donation, regular medical checkups, living wills, durable power of attorney for healthcare, and trusts. Gender-nonconforming individuals had significantly more familiarity with age preparatory behaviors than trans feminine individuals, but had lower levels of planning to engage in age preparatory behaviors than both trans masculine and trans feminine individuals.

Conclusion: The current findings highlight the need for providers to address age preparatory behaviors with TGNC individuals or provide referrals to support individuals in this planning.     

Self-harm prevalence and ideation in a community sample of cis,trans and other youth

Abstract

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.     

Counseling and Mental Health Care for Transgender Adults and Loved Ones

SUMMARY

Increasingly, transgender individuals and loved ones (partners, family, and friends) are seeking assistance from mental health professionals working in the community rather than in university or hospital-based gender identity clinics. Drawing on published literature specific to transgender mental health, interviews with expert clinicians, the authors' clinical experience, and three key guiding principles (a transgender-affirmative approach, client-centered care, and a commitment to harm reduction), we suggest protocols for the clinician providing mental health services in the community setting. Practice areas discussed include assessment and treatment of gender concerns, trans-specific mental health issues, and trans-specific elements in general counseling of transgender individuals and their loved ones.