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.     

The Uniqueness of Similarities: Parallels of Milton H. Erickson and Carl Rogers

The philosophy and values of Carl Rogers hold a central position in the counseling profession. Today the writings and work of Milton H. Erickson are beginning to have a similar influence. Erickson's strategies and techniques have been explored from many theoretical frames of reference, but little attention has been paid to his values regarding the human condition. It is these value assumptions of Rogers and Erickson that will be examined in this article.     

Queer ethics and fostering positive mindsets toward non-binary gender,genderqueer, and gender ambiguity

Abstract

Background: Alongside the growth in visibility of gender identities and presentations such as genderqueer, non-binary and gender neutral, there is ridicule and backlash in wider culture, as well as more subtle invisibility and misgendering. While there exists social psychology research about negative and positive attitudes to trans people, this is restricted to those whose gender identity is at odds with their sex assigned at birth, and who identify with binary gender. Social psychology has extended to the more subtle workings of transphobia, but there is little consideration of the distinctiveness of attitudes and responses to those whose genders cannot be attributed in binary ways, and thus how these may be challenged.

Methods: In keeping with the methods of social theory, this article brings together a diverse and complementary range of conceptual fields in new ways to diagnose a novel cause and solution to these negative attitudes. Using queer theory, feminist ethics, and empirical studies in post-tolerance sociology and social psychology, it argues that negative social responses to genderqueerness stem not only from overt prejudice in the form of transphobia but from binary genderism, the conviction that there are only two genders.

Results and conclusion: This article proposes fostering greater diversity-literacy and empathy for difference as a more effective approach than minority identity-based ‘prejudice reduction’ approaches. A norm-critical approach to deconstructing gender norms is proposed, thus fostering positive attitudes to genderqueerness. It is therefore demonstrated how best to foster enabling social contexts for genderqueerness, with positive implications for the physical and social health and wellbeing of gender variant people. This approach can be applied in organizations, institutions, and by service providers who interact with genderqueer individuals, in that it can inform a shift to approaching diversity positively in ways that are not restricted to pre-determined and binary identity categories.     

The “Transcendents” or “Trans” People

SUMMARY

This article was first published in Transvestia, vol. XVI, no. 95, 1978, pp. 81–92. Prince considers maleness and femaleness, and masculinity and femininity in human beings in terms of three dimensions: those of anatomy and physiology (the physical continuum), sex object choice (the psychological continuum), and the social and cultural continuum of masculinity and femininity. Socialisation traps us inside the two small permissible enclaves at the end of each continuum and in doing so produces “HALF HUMANS!” We accept this out of ignorance. As a humanist agitator, Prince advocates that we transcend the gender barrier and become free agents in regard to the transcended barrier. She distinguishes three types of trans people: transvestites (femmiphiles), transgenderists and transsexuals, and endorses the view that the woman most in need of liberation is the “woman” every man has locked in the dungeons of his own psyche.     

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.     

Experiences with stigmatization among transgender individuals after transition: A qualitative study in the Netherlands

Abstract

Background: Transgender individuals belong to one of the most stigmatized groups in society. Although the social stigma of transgender individuals has been examined many times, post transition stigma experiences among transgender individuals have received limited research attention. The aim of this study was to examine experiences with stigmatization among Dutch transgender individuals after their transition.

Method: Ten trans women (age: M?=?58.50, SD?=?9.49) and 10 trans men (age: M?=?42.90, SD?=?13.62) participated in face-to-face semistructured interviews. Grounded theory was used to conceptualize and analyze the data. We examined the positive and negative reactions that transgender individuals experienced in the period after their transition. Furthermore, we explored differences between experiences of trans men and trans women. Finally, we examined differences between cisgender men and women regarding their reactions toward transgender individuals.

Results: Participants reported improved psychological well-being since transition. However, they still experienced different forms of stigmatization. Trans women appeared to experience stronger social stigma than trans men. Trans women also experienced lower social status after their transition. They mainly experienced negative responses from cisgender men. Participants emphasized the importance of social and peer support.

Conclusion: The current study findings demonstrate the presence of stigmatization after transition and argue for psychological aftercare. Social and peer support appeared to be important for coping with stigmatization, and improving the social network of transgender individuals is beneficial. Health providers and researchers are recommended to promote the development of constructive coping skills for transgender individuals with interventions especially targeting trans women.     

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.     

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

“Queering” Spiritual Direction: Towards a Trans*-Literary Praxis

Abstract

The praxis of spiritual direction has a number of well-established orthodoxies, most notably Ignatian, Franciscan and Benedictine, each typically characterized as paths that invite us to become our “true” selves in God. This article interrogates practices of spiritual direction from a queer perspective, examining the exclusions and inclusions for trans* people implicit in traditional notions of “spiritual direction”. Concentrating on a theo-literary reading of Psalm 139 using trans* understandings of the terms “passing” and “stealth” and grounded in my experience as a trans* woman, a spiritual director and poet, this article presents critical strategies to enable trans* Christians to locate themselves in the Christian spiritual discourse.     

Reaction to Gunnison's Article on the Similarities Between Erickson and Rogers

Rogers and Erickson had no direct contact with each other's work. Whatever similarities exist developed independently. Rogers stresses his reliance on an intuitive relationship to the client's inner core and discusses the basis for this intuition. He also relies on a fundamental directional tendency which exists in every person. He trusts the client to choose his or her own goals. In these respects he sees some similarities between himself and Erickson, confirming Gunnison's points and going beyond them.     

Why Can’t You Just Pick One? The Stigmatization of Non-binary/Genderqueer People by Cis and Trans Men and Women: An Empirical Test of Norm-Centered Stigma Theory

Non-binary and genderqueer identities often resonate with people whose genders are outside the man-woman dichotomy, fluid, androgynous, and/or variant. Yet the gender binary system remains the unwavering norm, often placing non-binary and genderqueer people on the margins of social acceptability, and surprisingly little research has investigated those who stigmatize non-binary/genderqueer people. The current study utilizes Worthen’s (2020) Norm-Centered Stigma Theory (NCST) and nationally representative data collected from U.S. online panelists (n?=?3009: 1419 cis men, 1461 cis women, 74 trans women, 55 trans men) to investigate how norms (cisnormativity) and gender identity axes of social power (man/woman, cis/trans, and intersecting cis/trans-man/woman identities) relate to the stigmatization of non-binary/genderqueer people. Overall findings indicate that (a) cisnormativity is integral to understanding non-binary/genderqueer stigma, (b) the stigmatizer’s gender identity axes of social power are essential to explore as related to both cisnormativity and non-binary/genderqueer stigma, and (c) cisgender women are significantly different from others when it comes to both cisnormativity and non-binary/genderqueer stigma. Overall, the results underscore the significance of focusing on the unique complexities involved in the stigmatization of non-binary/genderqueer people and work toward dismantling such negativities.

     

“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.     

Physical activity and body image: Intertwined health priorities identified by transmasculine young people in a non-metropolitan area

Abstract

Background: A dearth of research exists about the health behaviors of transgender young people (TYP). As we seek to learn more about transgender (trans) health, community-based participatory research (CBPR) approaches are crucial for incorporating TYP’s needs into the formulation of research questions and development of health behavior programing.

Aim: Explore body image and exercise as priorities among TYP.

Methods: Trans masculine young adults (N?=?16) in a small city in the Midwest took part in semi-structured interviews about their health behaviors and priorities. Theme analysis was used to capture key patterns in participants’ responses. Specific analysis steps included initial and more specific coding, analytical memos, organizational matrices and reports, and discussion about results with participants.

Results: Participants identified exercise and body image as connected primary health concerns. They discussed these issues in terms of three themes: Body shape as motivation for exercise; Poor body image, stigma and fear as exercise barriers, and; Exercise or lack of, as destructive. Participants wanted to exercise to achieve a certain body shape, not for health or as stress relief. They cited gyms as unwelcoming, however. They also worried about discrimination and did not feel sufficiently comfortable with their bodies to exercise. When they could not exercise, they used harmful behaviors, like restricted eating, to achieve a specific male shape.

Conclusions: Using participatory methods allowed us to understand the priorities of a group of Transmasculine young people. Our findings suggest that it is important to continue to explore TYP’s body-related motivations for exercise and understand the balance between exercise as a positive health behavior, and a potentially harmful one, in light of TYP’s complex body image concerns. Trans friendly gyms and gym policies could promote safe exercise and continued anti trans discrimination work and policy advocacy can promote the safety of TYP in all spaces.     

Continuing education and training

Abstract

For over three quarters of a century Milton H. Erickson made an astonishing impact on all who met him and on all who were his patients. Unlike with many innovators, his recognition by colleagues did not wait for his death in 1980. For decades before people crowded to meet him, to be treated by him, and to learn from him. He was superbly fitted to be a clinician and a healer, thus it was his human and therapeutic qualities that were honored at a recent symposium at the Canterbury Group Family Institute in Great Neck, New York. The proceedings of that occasion are reported here by Laurie Klein Evans, Executive Director of the Institute.

I have already mentioned Erickson's unique position as a master healer. Also, during his lifetime and since his death, his work has inspired a prolific outpouring of theoretical contributions from colleagues and students. Haley has acknowledged his great debt to Erickson; the work of Bandler and Grinder, and of Selvini-Palazzoli, and the recent book by Keeney, Aesthetics of Change, all draw heavily on his practical applications and his natural wisdom in their fashioning of theoretical understandings, which range from paradox to field and system theory and cybernetics. It is small wonder, then, that as these theoretical advances continue, anecdotal and story-telling tributes also appear to bring further substantiation from the source of these exciting hypotheses.

—I.A.     

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.     

Organizing the voice questionnaire for transgender persons

Abstract

Background: The validated Transsexual Voice Questionnaire Male to Female (TVQ^MtF) and the adapted TVQ Female to Male (FtM) (TVQ^FtM) are both 30-item-long questionnaires used to evaluate self-perception of voice in transgender persons. They are part of a series of questionnaires completed by transgender persons during follow-up of cross-sex hormone therapy (CSHT).

Aim: The aim of this study was to examine if these questionnaires can be organized.

Methods: The TVQ^MtF or the TVQ^FtM was filled out at the start of CSHT, by 145 trans women and 83 trans men. Data were analyzed by factor analyses on both the questionnaires.

Results: The factor analyses resulted in a three-factor solution for both the TVQ^MtF and the TVQ^FtM. The three factors were labeled as anxiety and avoidance, vocal identity, and vocal function.

Conclusion: Both the questionnaires can be organized into three factors. This could contribute to making shorter versions of the questionnaires. Shorter versions would be useful to hormone prescribing physicians to track down more quickly voice problems in trans people undergoing virilizing or feminizing hormone treatment.     

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.     

Trans,gender diverse and non-binary adult experiences of social support: A systematic quantitative literature review

Abstract

Background: Trans, gender diverse and non-binary (TGDNB) adults experience significant health disparities relative to their cisgender peers. While social support is a known health-protective factor within the general population, no systematic reviews of TGDNB experiences of social support exist.

Aim: To systematically review prior research of social support for TGDNB adults. We sought to assess the defining characteristics of the research, the participants and the research findings, mapping emerging trends across disciplines.

Methods: Six electronic databases (PubMed, MEDLINE, CINAHL, Web of Science, LGBT Life and PsycNet) were searched for literature pertaining to TGDNB adults, social support, and health or well-being published in the past decade.

Results: The findings illustrate a predominance of USA-based quantitative research that measures social support of friends, family and a singular intimate partner. The majority of participants were white, binary-identified transgender women and TGDNB people living in metropolitan settings. Social support was commonly reported as a protective factor, with TGDNB peer support the most frequently reported correlate of health and well-being for TGDNB adults.

Discussion: The results suggest standardized inventories do not capture the emic nature of social support for TGDNB adults. A key opportunity lies in an inductive, hypothesis-forming approach to the study of what is socially supportive for TGDNB adults. In turn, this knowledge will enable the appropriate measurement, implementation and interpretation of social support studies.     

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.