• 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)
    • Genderqueer and non-binary genders

      Richards, Christina (2017)
      Non-binary or genderqueer people are those people who do not identify as male or female. They may have a fluid or a fixed notion of the degree of masculinity or femininity they have; or eschew the notion of a spectrum of gender altogether. The evidence regarding mental health is mixed; but there is certainly evidence that non-binary people are subject to societal opprobrium in many high GDP Western countries, which can lead to anxiety and depression. Accordingly, good clinical assistance should focus not only on the individual, but also on societal matter. Some non-binary people may seek physical interventions and there are limitations as to what may be achieved (c.f. Richards, Bouman & Barker, 2017), however for people who have carefully considered the matter these are very effective interventions. In short, non-binary people should be treated with respect and without undue attention being paid to the gender status. Where there are gender-specific considerations care should be given to ensure they are specific to individual need.
    • Good practice guidelines for the assessment and treatment of adults with gender dysphoria

      Bouman, Walter P. (2014)
      The Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria is a publication of the Intercollegiate Committee of the Royal College of Psychiatrists. The overall goal of the Good Practice Guidelines is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynaecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counselling, psychotherapy), and hormonal and surgical treatments. The Good Practice Guidelines are based on the best available science and expert professional consensus. The Good Practice Guidelines articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, the Good Practice Guidelines recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the Good Practice Guidelines to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • The good practice guidelines for the assessment and treatment of adults with gender dysphoria in the United Kingdom

      Bouman, Walter P. (2014)
      The Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria (Wylie et al., 2013) published in this issue of Sexual and Relationship Therapy are the Standards of Care for transgender people receiving support and medical care in the UK. These Guidelines provide clinicians with a framework to practice within and provide clients and patients with information as to what to expect from clinical services. The guide for general practitioners and other healthcare staff published last year reflected the care pathway patients and clients were receiving. The Good Practice Guidelines take one step further. This document sets out standards of care to adhere to with the aim to improve the quality of services for people with gender dysphoria as well as to strive towards a certain standardisation of care so that all clients and patients within a certain large geographical region receive a similar service. This must be seen as another positive development. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Historical background and theories regarding the causes of being transgender

      Bouman, Walter P.; Arcelus, Jon (2017)
      This chapter gives a brief historical overview of transgender people as well as (outdated) psychological theories and the development of medical treatment for transgender people. The main content of this chapter discusses various biological, psychological, social and cultural factors, which are thought to play a role in the development of being transgender. In particular, with regards to biological factors family studies, brain studies, hormonal studies and gene studies are described.
    • Identifying coping strategies used by patients at a transgender health clinic through analysis of free‐text autobiographical narratives

      Bouman, Walter P.; Arcelus, Jon (2021)
      Background This paper presents an analysis of 32 narratives written by patients waiting for assessment at a transgender health clinic (THC) in England. Narratives are autobiographical free texts, designed to allow patients to describe in their own words their experiences of their gender identity and/or transition prior to a clinic appointment, as part of the assessment process. Objective Narratives were analysed to identify actions prospective patients had taken to manage their (usually lengthy) waiting times, so that these ‘coping strategies’ could be shared with future patients. Design Corpus linguistic methodology was utilized to identify common patterns across the whole corpus of text‐based data, augmented with more detailed sociolinguistic analysis of individual narratives. Results There are broad commonalities in the way the transition experience is described across the corpus in terms of presentation of key experiences and feelings. There are specific descriptions of a number of recurring coping strategies, both positive and negative. Conclusion The empowerment value of writing these narratives may be limited; the existence of recurring key features suggests that patients may feel they have to present their experiences in certain ways to be accepted for treatment. However, dissemination of some positive coping strategies may help future clients of THCs to better cope with waiting times, as well as assisting practitioners in THCs in supporting their patients during this wait. Patient/Public Contribution The clinic's Service Users’ Research Advisory Group contributed to formulating the objective and design of the study. Results were presented at the clinic's annual PPI conference. (PsycInfo Database Record (c) 2021 APA, all rights reserved) (Source: journal abstract)
    • Interpersonal functioning among treatment‐seeking trans individuals

      Bouman, Walter P.; Arcelus, Jon (2015)
      Objectives: Trans people have been found to have high levels of depression. In view of the association between interpersonal problems and depression and the importance of interpersonal skills to navigate the transition of trans people, this study aims to investigate the levels of interpersonal problems among treatment-seeking trans men and women and the role of depression in this association. Method: A total of 104 patients from a UK gender identity clinic and 104 age- and gender-matched control participants completed self-report measures of interpersonal problems and general psychopathology, including depression. Results: Trans people reported significantly higher scores on global interpersonal problems and on the Inventory of Interpersonal Problems-32 (IIP-32) Hard to be Sociable, Hard to be Supportive, and Hard to be Involved subscales and lower scores on the Too Open subscale. Depression accounted for significant differences on IIP-32 global and the Too Open subscale but not on Hard to be Sociable, Hard to be Supportive, and Hard to be Involved subscales. Conclusions: Trans individuals present with interpersonal problems, which could potentially increase their vulnerability to mental health problems. Therefore, addressing interpersonal problems may help to prevent the development of depressive symptomatology and facilitate transition.
    • Introduction

      Richards, Christina (2015)