• 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 Experts in the field were contacted for unpublished results.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)
    • Investigating the outcome of the initial assessment at a national transgender health service: Time to review the process?

      Jones, Bethany A.; Brewin, Nicola; Richards, Christina; Van Eijk, Marnix; Stephenson-Allen, Alex; Arcelus, Jon (2017)
      Background: Globally, there is a lack of a standardized assessment process prior to the initiation of gender affirming medical interventions and consequently there is a discrepancy in this process among different transgender health services. Aim: The main objective of this study is to investigate the outcome of the initial assessment process at a national transgender health service. Method: The outcome of people over the age of 17 years, assessed at a large national transgender health service in the United Kingdom during a 2-year period was categorized into: (1) recommendation for cross-sex hormone treatment, or (2) no recommendation for cross-sex hormone treatment. In addition, 200 case notes were reviewed in order to investigate the level of agreement between the two clinicians involved in the assessment process. Results: During the study period, a total number of 617 people completed their assessment at the service. Following assessment 380 (61.6%) patients were recommended for cross-sex hormone treatment, leaving 237 (38.4%) patients who required a longer assessment period or were discharged. The factors associated with being recommended for cross-sex hormone treatment were having socially transitioned, not smoking, having initiated cross-sex hormones prior to assessment, being older, and assigned male at birth. Out of the 200 case notes reviewed, agreement between assessor 1 and 2 (3 months apart) was found in 88% (n = 176) of the cases. Discussion: Although the results of the study may not be generalizable to other international centers, questioning the assessment process and the role of the assessors is important to ensure treatment is offered in a timely and efficient manner. The findings from this study suggest that the routine inclusion of two assessors needs to be reviewed. © 2017 Taylor & Francis Group, LLC
    • 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.