• Language and terminology

      Arcelus, Jon; Bouman, Walter P. (2017)
      This chapter gives an overview of the terminology in the field of transgender healthcare. The word transgender is often used to describe anyone whose gender identity, expression or behaviour is different from the assigned gender at birth based on the sexual characteristics. The chapter describes a brief historical development of the concept of gender and gender role, and provides a list of terms related to transgender explaining what each term means in order to guide the reader throughout the book.
    • Language and trans health

      Bouman, Walter P. (2017)
    • The levels and predictors of physical activity engagement within the treatment seeking transgender population: A matched control study

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2017)
      BACKGROUND Physical activity has been found to alleviate mental health problems and could be beneficial for at-risk populations, such as transgender people. This study had three aims. First, to explore the amount of physical activity that treatment seeking transgender people engage in, and to compare this to matched cisgender people. Second, to determine whether there was a difference in physical activity depending on cross-sex hormone use. Third, to determine factors which predict physical activity among treatment seeking transgender people.METHODTransgender (n=360) and cisgender people (n=314) were recruited from the UK. Participants were asked to complete questionnaires about physical activity, symptoms of anxiety and depression, self-esteem, body satisfaction and transphobia.RESULTSTransgender people engaged in less physical activity than cisgender people. Transgender people who were on cross-sex hormones engaged in more physical activity than transgender people who were not. In transgender people on cross-sex hormones, high body satisfaction was the best statistical predictor of physical activity while high self-esteem was the best statistical predictor in people who were not.CONCLUSIONTransgender people are less active than cisgender people. Cross-sex hormone treatment appears to be able to indirectly increase physical activity within this population, which may be beneficial for mental well-being.
    • Levels of depression in transgender people and its predictors: Results of a large matched control study with transgender people accessing clinical services

      Bouman, Walter P.; Brewin, Nicola; Arcelus, Jon (2018)
      BACKGROUNDDepression is a serious disorder which significantly impacts wellbeing and quality of life. Studies exploring mental wellbeing in the transgender population are mostly limited by small, non-homogenous samples and lack of matched controls. This study aimed to address these limitations and explore depression rates in a large sample of transgender people, compared with matched controls from the general population, as well as factors predicting depression in those taking cross-sex hormone treatment (CHT) compared to those not.METHODSTransgender individuals (n = 913) completed a measure of depression, measures which predict psychopathology (self-esteem, victimization, social support, interpersonal problems), and information regarding CHT use. Participants were matched by age and experienced gender with adults from the general population who had completed the measure of depression.RESULTSIndividuals were categorized as having no, possible or probable depressive disorder. Transgender individuals not on CHT had a nearly four-fold increased risk of probable depressive disorder, compared to controls. Older age, lower self-esteem, poorer interpersonal function and less social support predicted depressive disorder. Use of CHT was associated with less depression.LIMITATIONSParticipants were attending a national gender identity service and therefore represent only a sub-group of transgender people. Due to the cross-sectional design, longitudinal research is required to fully confirm the finding that CHT use reduces depression.CONCLUSIONThis study confirms that non-treated transgender individuals have an increased risk of a depressive disorder. Interventions offered alongside gender affirming treatment to develop interpersonal skills, increase self-esteem and improve social support may reduce depression and prepare individuals for a more successful transition.
    • Long term effect of gender affirming hormone treatment on depression and anxiety symptoms in transgender people: A prospective cohort study

      Aldridge, Zoe; Patel, Shireen; Guo, Boliang; Nixon, Elena; Bouman, Walter P.; Arcelus, Jon (2020)
      BACKGROUNDCross-sectional studies show that transgender people are more likely than cisgender people to experience depression and anxiety before Gender Affirming Hormone Treatment (GAHT). However, the effect of GAHT on mental health in transgender people, and the role of other factors that may have a predictive effect, is poorly explored.OBJECTIVESUsing a longitudinal methodology, this study investigated the effect of 18 months GAHT on depression and anxiety symptomatology and the predictors on mental health outcomes in a large population of transgender people.MATERIALS AND METHODSParticipants (n=178) completed a socio-demographic questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Multidimensional Scale of Perceived Social Support (MSPSS) and the Autism Spectrum Quotient Short Version (AQ-short) at pre-assessment (T0) and at 18 months after initiation of GAHT (T1).RESULTSFrom T0 to T1, symptomatology was significantly decreased for depression (P <0.001) and non-significantly reduced for anxiety (P=0.37). Scores on the MSPSS predicted reduction in depression, while scores on the AQ-short predicted reduction in anxiety.DISCUSSIONGAHT reduces symptoms of depression which are predicted by having higher levels of social support. Although anxiety symptoms also reduce the changes are not significant and high levels of anxiety still remain post GAHT.CONCLUSIONSThese results highlight the important mental health benefits of GAHT. Support services (professional, third sector or peer-support) aiming at increasing social support for transgender individuals should be made available.
    • Mental health and gender dysphoria: A review of the literature

      Arcelus, Jon (2016)
      Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population. Copyright © 2016 © 2015 Taylor & Francis.
    • Mental health and quality of life in non-binary transgender adults: A case control study

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2019)
      AbstractBackground: The social challenges that non-binary people experience, due in part to social intolerance and the lack of validation of non-binary gender identities, may affect the mental health and quality of life of this population. However, studies that have distinguished between non-binary and binary transgender identities are lacking.Aim: To compare the mental health and quality of life of a community sample of non-binary transgender adults with controls (binary transgender people and cisgender people) matched on sex assigned at birth.Method: A total of 526 participants were included. Ninety-seven were classified as non-binary and were compared with two control groups: 91 people classified as binary and 338 cisgender people. Only transgender people not on gender affirming hormone treatment or who had not undergone gender affirming surgery were included. Participants were invited to complete an online survey that included mental health and quality of life measures.Results: Non-binary people reported significantly better mental health than binary transgender people, but worse than cisgender people. Overall, there were no significant differences in quality of life between non-binary and binary transgender participants assigned male at birth and transgender females, but non-binary assigned males at birth had better scores on the psychological and social domains of quality of life than transgender males. Quality of life was better across all domains in cisgender people than transgender groups.Conclusion: There is an inequality with regard to mental health and quality of life between non-binary (and binary) transgender people and the cisgender population that needs to be addressed. The better mental health scores in non-binary people may reflect lower levels of body dissatisfaction among the non-binary population. Mental health problems and poor quality of life are likely to have social causes and hence legislative measures and broader government-led inclusive directives should be put in place to recognize and to validate non-binary identifying people.
    • Mental health problems in the transgender population: what is the evidence?

      Arcelus, Jon (2017)
      This chapter discusses the findings from previous studies investigating mental health problems among transgender people. As most of the studies take place among people attending transgender health services the chapter will primarily focus on this group. The chapter will critically review the findings of the studies in order to make sure that they are relevant to the majority of the transgender people attending transgender health services. The chapter will divide the studies in two main categories, 1) those investigating how common mental health problems are in people by comparing them to cisgender groups and 2) studies looking as to how mental health problems change before and after treatment.
    • The need of patient involvement in transgender health care research

      Arcelus, Jon; Bouman, Walter P. (2017)
      In recent years, an unprecedented increase in clinical research in transgender health linked to a substantial increase in the clinical need of transgender people (in the broadest sense, ie, transgender, transsexual, and gender diverse) has been reported. In consequence, new professional networks such as the European Professional Association for Transgender Health (EPATH), the Australian and New Zealand Professional Association for Transgender Health, the Brazilian Professional Association for Transgender Health, and the United States Professional Association for Transgender Health (USPATH); specialist academic journals such as Transgender Studies Quarterly and Transgender Health; and specific sections on transgender health research in established journals such as the Journal of Sexual Medicine have emerged.
    • Non-binary or genderqueer genders

      Richards, Christina; Bouman, Walter P. (2016)
      Some people have a gender which is neither male nor female and may identify as both male and female at one time, as different genders at different times, as no gender at all, or dispute the very idea of only two genders. The umbrella terms for such genders are genderqueer' or non-binary' genders. Such gender identities outside of the binary of female and male are increasingly being recognized in legal, medical and psychological systems and diagnostic classifications in line with the emerging presence and advocacy of these groups of people. Population-based studies show a small percentage - but a sizable proportion in terms of raw numbers - of people who identify as non-binary. While such genders have been extant historically and globally, they remain marginalized, and as such - while not being disorders or pathological in themselves - people with such genders remain at risk of victimization and of minority or marginalization stress as a result of discrimination. This paper therefore reviews the limited literature on this field and considers ways in which (mental) health professionals may assist the people with genderqueer and non-binary gender identities and/or expressions they may see in their practice. Treatment options and associated risks are discussed.
    • Non-suicidal self-injury and suicidality in trans people: A systematic review of the literature

      Marshall, Ellen; Bouman, Walter P.; Witcomb, Gemma L.; Arcelus, Jon (2016)
      Literature has described high levels of mental health problems among trans people, such as depression, resulting in increased levels of non-suicidal self-injury (NSSI) behaviour and suicidality (suicidal thoughts, suicide attempts and suicide rates). With the aim of systematically reviewing the available literature in this field, this study identifies 31 papers that explore the rates of NSSI and suicidality in trans people. From reviewing the literature, it was revealed that trans people have a higher prevalence of NSSI and suicidality compared to the cisgender (non-trans) population. There appear to be some gender differences within these rates, with trans men at a greater risk for NSSI behaviour. Prevalence rates differ depending on the different stages of transition, but they are still overall greater than the cisgender population. The study concludes that trans individuals are at a greater risk of NSSI behaviour and suicidality than the cisgender population, and discusses risk factors and the need to develop effective preventative interventions. Copyright © 2015 © 2015 Institute of Psychiatry.
    • Non-suicidal self-injury in trans people: Associations with psychological symptoms, victimization, interpersonal functioning, and perceived social support

      Bouman, Walter P.; Witcomb, Gemma L.; Thurston, Megan; Arcelus, Jon (2015)
      Introduction: There is a paucity of systematic research in the area of non-suicidal self-injury (NSSI) in trans people. Aim: The aim of this study was to investigate the prevalence of NSSI in trans people and the associations with intra- and interpersonal problems. Methods Participants were 155 untreated individuals with a diagnosis of transsexualism (according to International Classification of Disease-10 criteria) attending a national gender identity clinic. Main Outcome Measures: All participants completed the Self-Injury Questionnaire, the Symptom Checklist-90-Revised, the Rosenberg Self-Esteem Scale, the Hamburg Body Drawing Scale, the Experiences of Transphobia Scale, the Inventory of Interpersonal Problems-32, and the Multidimensional Scale of Perceived Social Support. Results: The sample consisted of 66.5% trans women and 33.5% trans men and 36.8% of them had a history of engaging in NSSI. The prevalence of NSSI was significantly higher in trans men (57.7%) compared with trans women (26.2%). Trans individuals with NSSI reported more psychological and interpersonal problems and perceived less social support compared with trans individuals without NSSI. Moreover, the probability of having experienced physical harassment related to being trans was highest in trans women with NSSI (compared with those without NSSI). The study found that with respect to psychological symptoms, trans women reported significantly more intrapersonal and interpersonal symptoms compared with trans men. Finally, the results of the regression analysis showed that the probability of engaging in NSSI by trans individuals was significantly positively related to a younger age, being trans male, and reporting more psychological symptoms. Conclusions: The high levels of NSSI behavior and its association with interpersonal and interpersonal difficulties and lack of social support need to be taken into consideration when assessing trans individuals. The effect of cross-sex hormones and sex reassignment surgery on psychological functioning, including NSSI behavior, as part of the transitional journey of trans individuals should be explored in future studies. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • Patient satisfaction with gender identity clinic services in the United Kingdom

      Bouman, Walter P.; Richards, Christina; Baker, Karen; Murjan, Sarah; Mepham, Nick; Robbins-Cherry, Sally (2013)
      Measuring patient satisfaction is important in assessing healthcare outcomes due to the growing emphasis on greater partnership between providers and consumers. National Health Service (NHS) commissioning bodies in the United Kingdom increasingly expect patient satisfaction to be included as a service performance indicator as it is regarded as part of the definition of quality of care. The aim of this survey is to better understand levels of satisfaction with current gender identity clinic services (GICs) provision and to identify areas for improvement. A Patient Satisfaction Questionnaire (PSQ-GD) was developed specifically for use in GICs in the United Kingdom, which was given to all patients during one month. PSQ-GD covers clinical care, administrative and procedural issues as well as patient experience of local service provision from their General Practitioner, local psychiatric services and speech therapy. A total of 330 PSQ-GD were given with a response rate of 85%. Ninety-four percent would recommend the services if a friend or relative had a gender-related problem. Twenty percent were dissatisfied with the level of support for others close to the patient. Thirty-one percent were dissatisfied with local psychiatric services. Twenty-seven percent were dissatisfied with the wait for the first appointment. Administration scored high on satisfaction. A total of 222 positive and 131 negative comments were made. The PSQ-GD offers an opportunity to understand levels of satisfaction with current gender service provision and identifies areas for improvement, most notably the interface between GICs and local psychiatric services. Findings from this study put individual complaints in perspective and show that despite the challenges inherent in providing transgender care good satisfaction can be achieved. We encourage gender care providers to implement quality assurance and improvement procedures to give people with gender dysphoria the opportunity to provide feedback and have a voice in shaping their own health care. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • People with gender dysphoria who self-prescribe cross-sex hormones: Prevalence, sources, and side effects knowledge

      Bouman, Walter P.; Mepham, Nick (2014)
      Introduction: There is a scarcity of research into the use of non-physician-sourced cross-sex hormones in the transgender population. However, when medication is not prescribed by health professionals, users' knowledge of such medication may be adversely affected. Aims: This study aims to define the prevalence of Internet-sourced sex hormone use in a population attending for initial assessment at a gender identity clinic, to compare the prevalence between gender-dysphoric men and women, and to compare knowledge of cross-sex hormone side effects between users who source cross-sex hormones from medical doctors and those who source them elsewhere. Methods: In the first part of the study, a cross-sectional design is used to measure the overall prevalence of sex hormone use among individuals referred to a gender clinic. The second part is a questionnaire survey aiming at measuring sex hormone knowledge among individuals referred to this clinic. Main Outcome Measures: Main outcome measures were (i) categorical data on the prevalence and source of cross-sex hormone use and (ii) knowledge of sex hormone side effects in a population referred to a gender clinic. Results: Cross-sex hormone use was present in 23% of gender clinic referrals, of whom 70% sourced the hormones via the Internet. Trans men using testosterone had a sex hormone usage prevalence of 6%; one-third of users sourced it from the Internet. Trans women had a sex hormone usage prevalence of 32%; approximately 70% of users sourced hormones from the Internet. Cross-sex hormone users who sourced their hormones from physicians were more aware of side effects than those who used other sources to access hormones. Conclusion: One in four trans women self-prescribe cross-sex hormones before attending gender clinics, most commonly via the Internet. This practice is currently rare among trans men. Self-prescribing without medical advice leaves individuals without the knowledge required to minimize health risks. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • Physical activity and sport engagement in the transgender population

      Jones, Bethany A.; Arcelus, Jon (2017)
      This chapter provides an overview of the barriers and challenges that some transgender people experience when engaging in (or attempting to engage in) physical activity and sport. Throughout the chapter we will consider how socially and medically transitioning may interact with these barriers and affect physical activity and sport participation. The current policies regarding transgender people in competitive sport will also be discussed. We will then move on to exploring how physical activity and sport can be made more accessible and comfortable for transgender people.
    • Physical activity, exercise and sport participation in trans people: a qualitative study

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2016)
      Research suggests that physical activity, exercise and sport are not inclusive for the majority of trans individuals. To date, most of the research in this field has been conducted with people who self-identify as trans, relying on self-reports about cross-sex hormone therapy and or sex reassignment surgeries. Objective knowledge about stage of transition would aid an understanding about physical activity, exercise and sport engagement at different stages of transition. This would further highlight how trans people can be supported throughout their transition to ensure they can continue, or start, to participate in sport in a safe and inclusive environment. The aim of the current study was to explore the experiences of trans people in relation to physical activity, exercise and sport.