• Access to clinical services and the role of primary care

      Murjan, Sarah (2017)
      Transgender people face barriers to healthcare. There is a paucity of resources and transgender people often face delays in treatment. Services need to be sensitive to the needs of transgender patients, and primary care and specialist transgender healthcare services need to work together to provide holistic care. Primary care has a particular role in considering the fertility needs of transgender people having physical treatments, such as hormones and surgery, as well as looking after the long-term physical, mental and sexual health of patients who have had such treatments.
    • The amount and type of physical activity in trans people compared to cisgender people

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2016)
      Within the general population, physical activity levels are often below the recommended level, especially in females and older adults. Reasons for not engaging in physical activity include cost and physical mobility. In addition, certain populations may experience specific barriers, such as transphobia in trans people. Currently, only one study has explored physical activity in trans individuals and found levels to be significantly lower in comparison to cisgender people. However, the participants self-identified as trans, the samples were small, and cisgender and trans participants were not matched on any variable of importance. The current study aimed to explore the differences between trans and cisgender people, matched by age and gender (natal gender in the cisgender population and experienced gender in the trans population), in relation to the amount and type of physical activity they engage in.
    • Autistic traits in treatment-seeking transgender adults

      Nobili, Anna; Glazebrook, Cris; Bouman, Walter P.; Glidden, Derek; Arcelus, Jon (2018)
      The present study aimed to compare prevalence of autistic traits measured by the self-reported autism spectrum quotient-short (AQ-short) in a transgender clinical population (n = 656) matched by age and sex assigned at birth to a cisgender community sample. Results showed that transgender and cisgender people reported similar levels of possible autistic caseness. Transgender people assigned female were more likely to have clinically significant autistic traits compared to any other group. No difference was found between those assigned male. High AQ scores may not be indicative of the presence of an autism spectrum condition as the difference between groups mainly related to social behaviours; such scores may be a reflection of transgender people's high social anxiety levels due to negative past experiences.
    • Barriers and facilitators of physical activity and sport participation among young transgender adults who are medically transitioning

      Bouman, Walter P.; Jones, Bethany A.; Arcelus, Jon (2017)
      Background: Transgender people (those who feel incongruence between the gender they were assigned at birth and their gender identity) engage in lower levels of physical activity compared to cisgender (non-transgender) people. Several factors have been shown to affect physical activity engagement in the cisgender population; however, the physical activity experiences of young transgender adults have not been explored. It is therefore the aim of the current study to understand what factors are associated with physical activity and sport engagement in young transgender adults who are medically transitioning. Method: Semi-structured interviews were conducted with 14 young transgender adults (18–36 years) who had initiated their medical transition at a transgender health service in the United Kingdom. The data were analyzed using thematic analysis. Results: Two main themes were identified: (1) barriers and (2) facilitators to physical activity and sport. Overall, the young transgender adults were insufficiently active due to inadequate changing facilities, body dissatisfaction, fears surrounding "passing" and not being accepted by others. At the same time, participants were motivated to engage in physical activity to increase their body satisfaction and gender congruence. However, participants felt there was a lack of safe and comfortable spaces to engage in physical activity and sport. Conclusion: Young transgender adults who are medically transitioning experience several barriers to physical activity and sport, despite being motivated to be physically active. Initiatives to facilitate young transgender adults' ability to put their motivations into practice (i.e. to be more physically active) are needed. (PsycINFO Database Record (c) 2017 APA, all rights reserved) (Source: journal abstract)
    • Body dissatisfaction and disordered eating in trans people: A systematic review of the literature

      Jones, Bethany A.; Murjan, Sarah; Arcelus, Jon (2016)
      Body dissatisfaction plays a prominent role in gender dysphoria. In some individuals body dissatisfaction appears to manifest disordered eating in order to suppress bodily features of natal gender and accentuate features of gender identity. To date, there has been no systematic review of the literature pertaining to body dissatisfaction and disordered eating in trans individuals. Such a review may highlight important implications for clinicians working with trans people. Therefore, the aim was to critically and systematically review the available literature examining body dissatisfaction or disordered eating in a trans population, and also the literature pertaining to how body dissatisfaction and disordered eating are related in trans people. This review found three studies that explored disordered eating in trans people, five studies that explored body image and disordered eating in trans people, and 18 studies that explored body image in trans people. The findings from this review suggest that body dissatisfaction is core to the distress trans people experience and that this dissatisfaction may also put some individuals at risk of developing disordered eating. Additionally, the findings appear to suggest that gender dysphoria treatment is successful at increasing body satisfaction and improving body image. The clinical implications are discussed. Copyright © 2015 © 2015 Taylor & Francis.
    • Body image dissatisfaction and eating-related psychopathology in trans individuals: A matched control study

      Bouman, Walter P.; Richards, Christina; Arcelus, Jon (2015)
      High levels of body dissatisfaction have already been reported in the trans population; however, the root of this dissatisfaction, and its association with eating disordered behaviours, has not been studied in-depth. This study aims to assess eating disorder risk by comparing 200 trans people, 200 people with eating disorders and 200 control participants' scores on three subscales of the Eating Disorders Inventory-2 (EDI-2) and to further explore dissatisfaction in the trans participants using the Hamburg Body Drawing Scale (HBDS). The results showed that overall participants with eating disorders scored higher than trans or control groups on all EDI-2 measures, but that trans individuals had greater body dissatisfaction than control participants and, importantly, trans males had comparable body dissatisfaction scores to eating disordered males. Drive for thinness was greater in females (cis and trans) compared with males. In relation to HBDS body dissatisfaction, both trans males and trans females reported greatest dissatisfaction not only for gender-identifying body parts but also for body shape and weight. Overall, trans males may be at particular risk for eating disordered psychopathology and other body image-related behaviours.; Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association.
    • A comparison of mental health symptomatology and levels of social support in young treatment seeking transgender individuals who identify as binary and non-binary

      Thorne, Nat; Nixon, Elena; Arcelus, Jon (2018)
      Background: Previous research has consistently reported high rates of mental health symptomatology and lower social support in young treatment seeking transgender individuals. However, these studies have failed to distinguish between transgender people who identify within the gender binary and those who identify as non-binary. Aims: This study aimed to compare levels of mental health symptomatology (anxiety, depression, and non-suicidal self-injury behavior) and social support of treatment seeking non-binary transgender young individuals with those self-identified as binary transgender young individuals. All participants attended a national transgender health service in the UK during a 2-year period. Measures: Age and gender identity descriptors were collected, as well as clinical measures of anxiety and depression (Hospital Anxiety and Depression Scale), self-esteem (The Rosenberg Self-Esteem Scale), non-suicidal self-injury (Non-Suicidal Self-Injury: Treatment Related), and social support (Multidimensional Scale of Perceived Social Support). Results: A total of 388 young people, aged 16–25 years, agreed participation; 331 (85.3%) identified as binary and 57 (14.7%) as non-binary. Analysis of the data showed the non-binary group experienced significantly more anxiety and depression and had significantly lower self-esteem than the binary group. There were no significant differences between groups in the likelihood of engaging in non-suicidal self-injury behavior or levels of social support.Conclusions: Non-binary identifying treatment seeking transgender youth are at increased risk of developing anxiety, depression, and low self-esteem compared to binary transgender youth. This may reflect the even greater barriers and feelings of discrimination that may be faced by those whose identity does not fit the notion of binary gender that is pervasive in how society views both cis- and transgender populations. © 2018 Taylor & Francis Group, LLC
    • Current and future direction of gender dysphoria and gender incongruence research

      Bouman, Walter P.; Arcelus, Jon (2015)
      This article discusses about the current and future direction of gender dysphoria and gender incongruence research. Research in transgender health care is a relatively young discipline with hitherto little emphasis on multidisciplinary and international multicenter collaboration, and relatively few robust studies regarding outcome of physical interventions. There are a number of areas, which require robust investigation as appropriate data are lacking. Education and training of the public in general, from a young age onward, starting in schools, and healthcare professionals in particular, is vital to increase understanding and tolerance, and improve the quality of life of trans people and their loved ones. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Diagnostic and treatment issues for people with gender dysphoria in the United Kingdom

      Bouman, Walter P.; Richards, Christina (2013)
      This editorial is focused on the diagnostic and treatment issues for people with gender dysphoria in the United Kingdom. Terminology and diagnosis are important elements in the provision of clinical care which can offer a mutual language and framework, both clinical and bureaucratic, within which we can expediently work together for the benefit of our clients. The DSM-5 claims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than which they were assigned at birth. It makes several important clarifications in the criteria, chief of which is arguably the replacement of the diagnostic name Gender Identity Disorder with Gender Dysphoria. Clinicians from all disciplines within the United Kingdom, whether psychology, psychiatry, endocrinology, surgery, etc., are increasingly questioning the veracity of mental health diagnoses for trans people and, fortunately the World Health Organization (WHO) holds a similar view. The practice guideline in this issue is a shorter and more practical document than the Standards of Care (SoC), although its content remains analogous to, and in the spirit of, the UK SoC. As adherence to the legislative and existing clinical frameworks causes severe stress and anxiety in some patients, clinicians can be positioned such that they are unable to follow the bioethical principle of non-maleficence; this alone supports the argument that these frameworks ought to be critically appraised, further developed, and amended as evidence and clinical experience evolve. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Endocrinology of transgender medicine

      Arcelus, Jon (2018)
      Gender affirming treatment for transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen lowering medications. Feminizing treatment with estrogens and anti-androgens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk of venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses plus increase of muscle mass, facial and body hair. Due to the lack of evidence, treatment for gender non-binary people should be individualized. Young people may receive pubertal suspension, consisting of gonadotrophin-releasing hormone analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur, but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to effect of gender affirming treatment in the non-binary population.
    • European Society for Sexual Medicine position statement “Assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction”

      Arcelus, Jon (2020)
      Background: There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice. Aim: We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction. Methods: The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available. Outcomes: The foci of the study are assessment and hormonal aspects of trans health care. Results: As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment. Clinical Implications: This is an up-to-date ESSM position statement. Strengths & Limitations: These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited. Conclusion: This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction”. J Sex Med 2020;17:570–584. © 2020 International Society for Sexual Medicine
    • Examining risk factors for self-harm and suicide in LGBTQ+ young people: a systematic review protocol

      Arcelus, Jon (2019)
      INTRODUCTIONYoung people who identify as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (LGBTQ+) are at increased risk for self-harm, suicide ideation and behaviours. However, there has yet to be a comprehensive understanding of what risk factors influence these behaviours within LGBTQ+ young people as a whole. The purpose of this systematic review is to examine risk factors associated with self-harm, suicidal ideation and behaviour in LGBTQ+) young people.METHODS AND ANALYSISA systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (MEDLINE, Scopus, EMBASE, PsycINFO and Web of Science) will be systematically searched for cross-sectional, prospective, longitudinal, cohort and case-control designs which examine risk factors for self-harm and/or suicidal ideation and behaviour in LGBTQ+ young people (aged 12-25 years). Only studies published in English will be included. No date restrictions will be applied. Study quality assessment will be conducted using the original and modified Newcastle-Ottawa Scales. Meta-analysis or narrative synthesis will be used, dependent on findings.ETHICS AND DISSEMINATIONThis is a systematic review of published literature and thereby ethical approval was not sought. The review will be submitted to a peer-reviewed journal, be publicly disseminated at conferences focusing on mental health, self-harm and suicide prevention. The findings will also be shared through public engagement and involvement, particularly those related to young LGBTQ+ individuals.PROSPERO REGISTRATION NUMBERCRD42019130037.
    • Expanding the evidence: Developments and innovations in clinical practice, training and competency within voice and communication therapy for trans and gender diverse people

      Georgiadou, Ioanna (2017)
      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 (TVQMtF); 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. © 2017 Taylor & Francis Group, LLC
    • Experiences and psychological wellbeing outcomes associated with bullying in treatment-seeking transgender and gender-diverse youth

      Bouman, Walter P.; Nixon, Elena; Arcelus, Jon (2019)
      Purpose: Bullying in the adult transgender population is well documented, but less is known about bullying in transgender and gender-diverse (TGD) youth. Studies have begun to explore experiences of bullying and the associated psychological distress in TGD youth; however, they often fail to distinguish among the separate groups within LGBT samples. This study sought to explore the prevalence, nature, and outcomes of bullying in TGD youth attending a transgender health service in the United Kingdom, taking into account birth-assigned sex and out and social transition status. Methods: Before their first appointment at a specialist gender clinic, participants completed a brief sociodemographic questionnaire, a questionnaire assessing experiences and outcomes of bullying, and a clinically validated measure of anxiety and depression (Hospital Anxiety and Depression Scale). Results: A total of 274 TGD people aged 16-25 years participated in the study. The majority of participants (86.5%) reported having experienced bullying, predominantly in school. Bullying was more prevalent in birth-assigned females and in out individuals, and commonly consisted of homophobic/transphobic (particularly in socially transitioned individuals) or appearance-related (particularly in out individuals) name calling. Individuals who reported having experienced bullying showed greater anxiety symptomology and also self-reported anxiety, depression, and low self-esteem as effects of bullying. Birth-assigned females also reported greater effects on family relationships and social life. Conclusion: These findings indicate very high levels of bullying within the young TGD population attending a transgender health service in the United Kingdom, which affects wellbeing significantly. More intervention work and education need to be introduced in schools to reduce bullying.
    • Further genders

      Richards, Christina (2015)
      In this chapter, we cover those gender forms which fall outside the common binary of women and men. However, as we will see, bisecting the world into women and men — or, indeed, women, men, and others — is not necessarily a useful way of conceptualising things. Consequently, we have entitled this chapter ‘Further Genders’ in order to be comprehensible to readers who are unfamiliar with gender forms other than woman or man (whether trans or cisgender1).
    • Further sexualities

      Richards, Christina (2015)
    • Gender congruence and body satisfaction in nonbinary transgender people: A case control study

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2019)
      Background: Binary transgender people access gender affirming medical interventions to alleviate gender incongruence and increase body satisfaction. Despite the increase in nonbinary transgender people, this population are less likely to access transgender health services compared to binary transgender people. No research has yet understood why by exploring levels of gender congruence and body satisfaction in nonbinary transgender people. Objective: The aim of this study was to compare levels of gender congruence and body satisfaction in nonbinary transgender people to controls [binary transgender people and cisgender (nontrans) people]. Method: In total, 526 people from a community sample in the UK took part in the study (97 nonbinary, 91 binary, and 338 cisgender identifying people). Participants were asked to complete an online survey about gender congruence and body satisfaction. Results: There were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender and body satisfaction compared to binary transgender people. However, there was no difference in congruence and satisfaction with social gender role between the two transgender groups (nonbinary and binary). Cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary). Conclusions: There are differences in gender congruence and body satisfaction between nonbinary and binary transgender people. Nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people. Transgender health services need to be more inclusive of nonbinary transgender people and their support and treatment needs, which may differ from those who identify within the binary gender system. © 2019, © 2019 Taylor & Francis Group, LLC.
    • The Gender Congruence and Life Satisfaction Scale (GCLS): Development and validation of a scale to measure outcomes from transgender health services

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2018)
      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.