• 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.
    • Gender dysphoria

      Bouman, Walter P. (2016)
    • Gender dysphoria and autism spectrum disorder: A systematic review of the literature

      Glidden, Derek; Bouman, Walter P.; Jones, Bethany A.; Arcelus, Jon (2016)
      Introduction: There is a growing clinical recognition that a significant proportion of patients with gender dysphoria have concurrent autism spectrum disorder (ASD). Aim: The purpose of this review is to systematically appraise the current literature regarding the co-occurrence of gender dysphoria and ASD. Methods: A systematic literature search using Medline and PubMed, PsycINFO, and Embase was conducted from 1966 to July 2015. Main Outcome Measures: Fifty-eight articles were generated from the search. Nineteen of these publications met the inclusion criteria. Results: The literature investigating ASD in children and adolescents with gender dysphoria showed a higher prevalence rate of ASD compared with the general population. There is a limited amount of research in adults. Only one study showed that adults attending services for gender dysphoria had increased ASD scores. Another study showed a larger proportion of adults with atypical gender identity and ASD. Conclusion: Although the research is limited, especially for adults, there is an increasing amount of evidence that suggests a co-occurrence between gender dysphoria and ASD. Further research is vital for educational and clinical purposes. Copyright © 2016 International Society for Sexual Medicine.
    • Gender dysphoria and gender incongruence: An evolving inter-disciplinary field

      Bouman, Walter P. (2016)
      This editorial provides an overview of the articles featured in this issue of International Review of Psychiatry. One of the article discuss the changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification of gender identity-related conditions over time, and indicate how these changes were associated with the changes in conceptualization of gender dysphoria and gender incongruence. Another article found that empirically, there is no link between sexual orientation and outcome of transition-related health care for trans* adults. They do recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions, and stress that this knowledge should not drive, but simply inform the provision of comprehensive clinical care. It is hoped that these articles will enhance the knowledge of its reader in the field of psychiatry. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Gender dysphoria and intellectual disability: Presentation, diagnosis and course

      Bouman, Walter P. (2015)
      Objectives: What are the differences in presentation and course in gender dysphoria (as defined by DSM-5) in people with ID compared to the general population? Methods: A literature search was carried out from 1966 to 2014 of all major medical databases. Experts in the field were contacted for unpublished results. Results: The papers found through the literature search will be discussed, including Parkes et al 2009 and Bedard et al 2010. Conclusions: People with intellectual disability often present later in life, sometimes after a change in circumstance e.g. a parent dying or moving out of a long stay institution. Mode of presentation can be cross dressing, challenging behaviour. The cross dressing itself can be seen as a challenge to networks. Some as adults show delayed development in gender constancy and also mistaken beliefs. There can be late remissions. People may experience stigma, victimisation or abuse.
    • Gender dysphoria services: A guide for general practitioners and other healthcare staff

      Bouman, Walter P.; Murjan, Sarah; Richards, Christina (2013)
      This guide reflects current practice of National Health Service (NHS) gender clinic services in the United Kingdom (UK). The NHS offers healthcare free at the point of access. The guide describes how and when people with gender dysphoria should be referred; and what people with gender dysphoria can expect in terms of assessment, treatment, care and support from gender clinic services. This guide has been written by clinicians of the four largest gender clinic services in England. An early draft of this guide was shared with all UK gender clinic services for their input, following which trans people and other relevant stakeholders were consulted and given an extensive opportunity to comment on the draft guide. This guide is intended to inform primary care physicians, known in the UK as general practitioners, as well as all other relevant gender-related healthcare and psychotherapy service providers, both NHS and privately, commissioning bodies, and people with gender dysphoria. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • Gender incongruence of adolescence and adulthood: Acceptability and clinical utility of the World Health Organization's proposed ICD-11 criteria

      Bouman, Walter P.; Arcelus, Jon; Richards, Christina (2016)
      The World Health Organization (WHO) is currently updating the tenth version of their diagnostic tool, the International Classification of Diseases (ICD, WHO, 1992). Changes have been proposed for the diagnosis of Transsexualism (ICD-10) with regard to terminology, placement and content. The aim of this study was to gather the opinions of transgender individuals (and their relatives/partners) and clinicians in the Netherlands, Flanders (Belgium) and the United Kingdom regarding the proposed changes and the clinical applicability and utility of the ICD-11 criteria of 'Gender Incongruence of Adolescence and Adulthood' (GIAA). A total of 628 participants were included in the study: 284 from the Netherlands (45.2%), 8 from Flanders (Belgium) (1.3%), and 336 (53.5%) from the UK. Most participants were transgender people (or their partners/relatives) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both healthcare providers and (partners/relatives of) transgender people. Participants completed an online survey developed for this study. Most participants were in favor of the proposed diagnostic term of 'Gender Incongruence' and thought that this was an improvement on the ICD-10 diagnostic term of 'Transsexualism'. Placement in a separate chapter dealing with Sexual- and Gender-related Health or as a Z-code was preferred by many and only a small number of participants stated that this diagnosis should be excluded from the ICD-11. In the UK, most transgender participants thought there should be a diagnosis related to being trans. However, if it were to be removed from the chapter on "psychiatric disorders", many transgender respondents indicated that they would prefer it to be removed from the ICD in its entirety. There were no large differences between the responses of the transgender participants (or their partners and relatives) and HCPs. HCPs were generally positive about the GIAA diagnosis; most thought the diagnosis was clearly defined and easy to use in their practice or work. The duration of gender incongruence (several months) was seen by many as too short and required a clearer definition. If the new diagnostic term of GIAA is retained, it should not be stigmatizing to individuals. Moving this diagnosis away from the mental and behavioral chapter was generally supported. Access to healthcare was one area where retaining a diagnosis seemed to be of benefit.
    • Gender incongruence of childhood: Clinical utility and stakeholder agreement with the World Health Organization's proposed ICD-11 criteria

      Bouman, Walter P.; Arcelus, Jon; Richards, Christina (2017)
      The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.
    • Genderdysforie [Gender dysphoria]

      Bouman, Walter P. (2019)
    • Genderqueer and non-binary genders

      Richards, Christina; Bouman, Walter P. (2017)