• 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.
    • Predictors of psychological well-being among treatment seeking transgender individuals

      Bouman, Walter P.; Arcelus, Jon (2016)
      Research has yet to identify specific predictors of poor psychological well-being and quality of life in transgender people. This study aimed first to explore the predictive value of five factors known to be associated with poor psychological well-being in cis- and transgender people; age, self-esteem, victimisation, interpersonal problems, and body dissatisfaction. Second, to investigate the mediatory role of self-esteem and social support. Two hundred and eight participants (104 transgender and 104 cisgender controls), matched by age and gender, completed measures of these predictor variables, along with general psychopathology and functional quality of life. The results indicate that in the transgender group, greater psychopathology and greater depression were predicted by younger age (psychopathology only), lower self-esteem, greater body dissatisfaction, and greater interpersonal problems. In the cisgender group, only lower self-esteem and greater interpersonal problems were significant predictors of these factors. For quality of life, lower self-esteem and greater interpersonal problems were significant predictors of low quality of life in both groups. Self-esteem but not social support mediated the above relationships. Overall, self-esteem and interpersonal problems appear to be crucial factors that influence well-being. Those providing treatment to transgender people should pay more attention to these areas.
    • Prospective evaluation of self-reported aggression in transgender persons

      Bouman, Walter P.; Brewin, Nicola; Arcelus, Jon (2018)
      Background: Although research on the relation between testosterone and aggression in humans is inconclusive, guidelines (including the World Professional Association for Transgender Health Standards of Care, edition 7) have warned for an increase in aggression in transgender men taking testosterone treatment. Aims: To investigate the association between levels of testosterone and aggression in treatment-seeking transgender people and explore the role of mental health psychopathology (anxiety and depressive symptoms) and social support in aggression in this population. Methods: Every transgender person invited for assessment at a national transgender health clinic in the United Kingdom during a 3-year period (2012–2015) completed self-report measures for interpersonal problems, including levels of aggression (Inventory of Interpersonal Problems [IIP-32]), symptoms of anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), social support (Multidimensional Scale of Perceived Social Support), and experiences of transphobia before and 1 year after the initiation of gender-affirming hormonal therapy. Correlations between prospective scores for the IIP-32 factor “too aggressive” and prospective levels of sex steroids, prospective psychological (HADS), and baseline psychosocial measurements were tested. Outcomes: Prospective scores for the factor “too aggressive” were not correlated to prospective serum testosterone levels. Results: Results of 140 people (56 transgender men, 84 transgender women) were analyzed. A prospective increase in scores for the factor “too aggressive” of the IIP-32 in transgender men 1 year after being treated with testosterone treatment or a decrease of the IIP-32 aggression scores in transgender women 1 year after gender-affirming hormonal therapy was not found. However, a positive correlation was found between increasing HADS anxiety scores and increasing scores for the IIP-32 “too aggressive” score in the entire study population and a positive correlation with lower support from friends in transgender women. Clinical Implications: Hormone-prescribing physicians can be reassured that the long-term administration of testosterone in transgender men does not increase aggressive behavior. Strengths and Limitations: This is the 1st prospective study to assess the effect of gender-affirming hormonal care on aggression. Limitations included the use of different laboratories, the use of a patient-reported outcome measure, and the lack of aggression subtypes. Conclusions: Testosterone therapy was not associated with an increase in levels of aggression in transgender men or a decrease in aggressive behavior in transgender women on antiandrogen and estrogen therapy, but other psychological and/or social factors, such as anxiety levels, appear to contribute to self-reported aggression in transgender people.
    • Psychiatry

      Murjan, Sarah; Bouman, Walter P. (2017)
    • The quality and satisfaction of romantic relationships in transgender people: A systematic review of the literature

      Marshall, Ellen; Glazebrook, Cris; Robbins-Cherry, Sally; Thorne, Nat; Arcelus, Jon (2020)
      Introduction: Romantic relationships are often a significant area of individuals’ lives and can have a positive impact on wellbeing. There is often a belief within society of romantic relationships ending upon the start of gender affirming transition, however this is often not reflected within clinical work or research studies. Despite this, currently not enough is known about romantic relationships for transgender individuals and their partners, and the impact gender affirming transition can have on the quality and satisfaction of these relationships. Aim: To critically and systematically review the available literature examining quality and satisfaction of romantic relationships for transgender individuals and their partners. Methods: Using PRISMA guidelines, major databases (Pubmed, PsycINFO and Web of Science) and relevant reference lists were searched for suitable articles up to January 2020. Each included article was assessed for methodological quality and the demographic data, methods and findings linked to relationship quality and satisfaction was extracted for analysis. Results: From 151 potentially relevant articles, 14 studies (six quantitative, eight qualitative) were included within the review. Most studies displayed moderate risk of bias due to cross-sectional designs and lack of reflexivity. Findings from quantitative studies suggest a bi-directional relationship between transition, relationship quality and satisfaction and wellbeing. Qualitative studies suggest transition can cause personal challenges for both transgender individuals and partners. Maintenance activities help buffer the impact of these challenges on relationship satisfaction and ensure positives are possible from relationships. Discussion: Gender affirming transition can impact on the quality and satisfaction of romantic relationships. Due to additional challenges transgender individuals and their partners may face, adequate support is required at personal, community and clinical level. There is a paucity of research in this area and current studies lack methodological rigor. Future research is essential to gain a further understanding of transgender relationships and the support required. © 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.
    • Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis

      Nobili, Anna; Glazebrook, Cris; Arcelus, Jon (2018)
      The study aims to systematically extract and analyse data about Quality of Life (QoL) in the transgender population. A systematic literature search and meta-analysis were conducted using the MEDLINE, EMBASE, PubMed, and PsycINFO databases, up to July 2017. Only English language quantitative studies, in adults, which reported the means for validated QoL measures were included. Random-effect meta-analysis was adopted to pool data and estimate the 95% Confidence Intervals (CI). From 94 potentially relevant articles, 29 studies were included within the review and data extraction for meta-analysis was available in 14 studies. The majority of the studies were cross-sectional, lacked controls and displayed moderate risk of bias. Findings from the systematic review suggested that transgender people display poor QoL, independent of the domain investigated. Pooling across studies showed that transgender people report poorer mental health QoL compared to the general population (-0.78, 95% CI = -1.08 to -0.48, 14 studies). However, meta-analysis in a subgroup of studies looking at QoL in participants who were exclusively post-CHT found no difference in mental health QoL between groups (-0.42, 95% CI = -1.15 to 0.31; 7 studies). There was insufficient data for a pre-treatment subgroup. Evidence suggests that transgender people have lower QoL than the general population. Some evidence suggests that QoL improves post-treatment. Better quality studies that include clearly defined transgender populations, divided by stage of gender affirming treatment and with appropriate matched control groups are needed to draw firmer conclusions.<br/>Copyright &#xa9; 2018, The Author(s).
    • Risk factors for eating disorder psychopathology within the treatment seeking transgender population: The role of cross-sex hormone treatment

      Jones, Bethany A.; Bouman, Walter P.; Arcelus, Jon (2018)
      Many transgender people experience high levels of body dissatisfaction, which is one of the numerous factors known to increase vulnerability to eating disorder symptoms in the cisgender (non-trans) population. Cross-sex hormones can alleviate body dissatisfaction so might also alleviate eating disorder symptoms. This study aimed to explore risk factors for eating disorder symptoms in transgender people and the role of cross-sex hormones. Individuals assessed at a national transgender health service were invited to participate (N = 563). Transgender people not on cross-sex hormones reported higher levels of eating disorder psychopathology than people who were. High body dissatisfaction, perfectionism, anxiety symptoms, and low self-esteem were risk factors for eating psychopathology, but, after controlling for these, significant differences in eating psychopathology between people who were and were not on cross-sex hormones disappeared. Cross-sex hormones may alleviate eating disorder psychopathology. Given the high prevalence of transgender identities, clinicians at eating disorder services should assess for gender identity issues. Copyright (c) 2018 John Wiley & Sons, Ltd and Eating Disorders Association.
    • Risk factors for non-suicidal self-injury among trans youth

      Arcelus, Jon; Marshall, Ellen; Bouman, Walter P. (2016)
      INTRODUCTION: Previous research has reported high levels of non-suicidal self-injury (NSSI) in trans populations and younger age has been identified as a risk factor.
    • SAT-014 No correlation between serum testosterone levels and aggresion or anger intensity in transgender people: Results from five European centres

      Arcelus, Jon; Bouman, Walter P.; Brewin, Nicola (2019)
      AIM: Anger is a state of emotions ranging from irritation to intense rage. Aggression is the externalization of anger through destructive/punitive behaviour. The World Professional Association for Transgender Health (WPATH) Standards of Care, Edition 7 (SOC7) guidelines warn about aggression in transgender men (TM) on testosterone treatment. We aimed to assess whether aggression and anger intensity increase in TM and decrease in transgender women (TW) after initiation of gender affirming hormone therapy and to identify predictors for anger intensity in transgender people, including levels of sex steroids as well as psychological measurements. METHODS: Prospective changes in aggression were measured at baseline and after one year of gender affirming hormones in 155 transgender persons (64 TM, 91 TW), using the Inventory of Interpersonal Problems (IIP-32) factor ‘too aggressive’. State-level anger intensity was prospectively assessed in 898 participants (440 TM, 468 TW) by the STAXI-2 (State-Trait Anger Expression Inventory-2) State Anger (S-Anger) questionnaire during a three-year follow-up period, starting at the initiation of hormone treatment (testosterone in TM, oestrogens plus anti-androgens in TW). At baseline, psychological questionnaires were administered. Data were analysed cross-sectionally and prospectively. RESULTS: No prospective changes were reported in ‘too aggressive’ scores (after one year of hormone therapy) and S-Anger scores (over 3, 12 and 36 months of hormone therapy) in TM and TW. ‘Too aggressive’ scores were positively correlated to increasing anxiety scores in the entire study population and with lower support from friends in TW. At three, twelve and thirty-six months of gender affirming hormone therapy, anger intensity was not correlated to serum testosterone levels, although there was a correlation with various psychological measures after three and twelve months. TM experiencing menstrual spotting after three months had higher S-Anger scores compared to those without (median 26.5 [18.0 - 29.8] versus 15.0 [15.0 - 17.0], P=0.020). Changes in STAXI-2 S-Anger scores were not correlated to changes in serum testosterone levels after three, twelve and thirty-six months in TM or TW. CONCLUSIONS: Aggression and state-level anger intensity are associated with psychological and/or psychiatric vulnerability or the persistence of menses in TM, but not with exogenous testosterone therapy in TM or serum testosterone levels in both TM and TW.
    • Self-injury among trans individuals and matched controls: Prevalence and associated factors

      Arcelus, Jon; Bouman, Walter P. (2015)
      This study aims to determine the prevalence rate of current non-suicidal self-injury (NSSI) among trans individuals, in comparison with a control sample of non-trans adults. It also aims to compare those with current NSSI and those with no history of NSSI in terms of psychological well-being, self-esteem, body dissatisfaction, social support and demographic factors. Participants were 97 adults, diagnosed with transsexualism (ICD-10, F64.0), attending a national gender clinic in the United Kingdom, and a matched control group. Clinical participants were all engaged on the treatment pathway. Participants completed the following self-report measures: Self-Injury Questionnaire - Treatment Related (SIQ-TR), Symptom Checklist 90 Revised (SCL-90-R), Rosenberg Self-Esteem Scale (RSE), Hamburg Body Drawing Scale (HBDS) and Multidimensional Scale of Perceived Social Support (MSPSS). The results showed that the trans participants had a significantly higher prevalence of current NSSI behaviour than the non-trans group, with 19% currently engaging in NSSI. Current NSSI was also significantly more prevalent among trans men than trans women. Compared with both trans and non-trans participants with no history of NSSI, trans participants with current NSSI had significantly higher scores on SCL; significantly lower scores on RSE, HBDS and MSPSS; and were younger in age. The study concludes that trans men, specifically, are more at risk of NSSI than trans women and the general population, even when on the treatment pathway. Those who currently self-injure have greater psychopathology, lower body satisfaction, lower self-esteem, lower social support and tend to be younger, than those who do not engage in NSSI. © 2015 John Wiley & Sons Ltd.
    • Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking

      Richards, Christina (2016)
      Since the beginning of contemporary transition-related care at the outset of the 20th century, sexual orientation has ben considered to be closely connected with gender identity and the developmental trajectories of trans people. Specifically, health professionals have regarded the anticipated post-transitional heterosexual behaviour of trans adults as predictive of a good outcome of cross-sex hormones and gender-confirming surgeries. This article reviews the current literature according to the question of whether the sexual orientation of trans people is linked to outcome measures following transition-related interventions. A comprehensive review was undertaken using the Medline database, searching for empirical studies published between 2010 and 2015. Out of a total of 474 studies, only 10 studies reported a follow-up of trans adults and assessed sexual orientation in the study protocol at all. Sexual orientation was predominantly assessed as homosexual versus non-homosexual related to sex assigned at birth. Only one 1 of 10 follow-up studies found a significant association according to the outcome between groups differentiated by sexual orientation. Empirically there is no link between sexual orientation and outcome of transition-related health care for trans adults. In order to provide comprehensive health care, we recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions; however, this knowledge should not drive, but simply inform, such comprehensive care. 2016 Copyright © 2016 Taylor & Francis.
    • Social support and psychological well-being in gender dysphoria: A comparison of patients with matched controls

      Bouman, Walter P.; Arcelus, Jon (2014)
      Introduction: There is a paucity of research in the area of social support and psychological well-being among people with gender dysphoria. Aims: The present study aimed to investigate levels of social support among individuals with gender dysphoria compared with a matched control group. It also aimed to examine the relationship between social support and psychological well-being. Methods: Participants were 103 individuals diagnosed with gender dysphoria (according to ICD-10 criteria) attending a national gender identity clinic and an age- and gender-matched nonclinical control group recruited via social networking websites. Main Outcome Measures: All participants completed measures of social support (Multidimensional Scale of Perceived Social Support, MSPSS), psychopathology (Symptom Checklist 90 Revised, SCL), quality of life (Short Form 36 version 2, SF), and life satisfaction (Personal Wellbeing Index, PWI). Results: Trans women reported significantly lower MSPSS total and MSPSS family scores compared with control women, although these differences in levels of social support were no longer significant when SCL depression was controlled for. No significant differences were found between trans men and any other group. MSPSS scores did not significantly predict SCL subscales but did predict both SF subscales and PWI total scores. Conclusions: Trans women perceived themselves to be lacking social support. Given that social support is beneficial to quality of life and life satisfaction in those with gender dysphoria, this is of great concern. Though these findings have been derived from correlational results, extended research may highlight the value of clinicians helping trans women to seek out and maintain social support. Additionally, efforts could be made to educate and challenge attitudes of nontrans people towards those with gender dysphoria. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)