"Banned by Silence": Provider stigma, systemic decay, and the inaccessibility of gender-affirming healthcare in Morocco

ABSTRACTBackground: Transgender and gender nonconforming (TGNC) individuals experience an increased prevalence of many psychological disorders, leading many to reach out for support from family, friends, mental health professionals, and religious or community networks. Nonetheless, experiences seeking support are often negative, and many psychotherapists report feeling underprepared to work with TGNC clients. To better understand the experiences of TGNC individuals and better equip psychotherapists in their work with TGNC clients, we investigate which sources of support most successfully buffer psychological distress among TGNC individuals.Aims: This study aims to identify differences in levels of various types of support (social, family, religious, and living-situation) between cisgender and TGNC individuals and examine how these types of support may or may not buffer psychological distress among TGNC individuals.Method: We used a United States national sample of 3,090 students (1,030 cisgender men; 1,030 cisgender women; 349 transgender; 681 endorsing another gender identity) from the Center for Collegiate Mental Health 2012–2015 database which provided basic demographic information through the Standardized Data Set. Psychological distress was measured through the Counseling Center Assessment of Psychological Symptoms 34-item questionnaire.Results: TGNC individuals reported more distress, less family support, more social support, and less frequent religious affiliation than cisgender men and women. Family and social support emerged as the strongest predictors of distress for both TGNC and cisgender individuals. Though religious affiliation and living on-campus buffered distress among cisgender students, they did not buffer distress among TGNC students.Conclusion: Our study highlights disparities in distress and support between TGNC and cisgender individuals. We found that although religious affiliation and on-campus living are beneficial for cisgender students, neither systematically buffers distress for TGNC students. These findings illustrate the impact minority stress and systemic discrimination may have on TGNC individuals and provide suggestions for therapeutic intervention in work with TGNC individuals.

Transgender and gender nonconforming (TGNC) individuals interact with mental health care systems at high rates and experience substantial barriers to care. Rural TGNC individuals face additional disparities in accessing appropriate mental health services. Little research has focused on the mental health care providers who work with TGNC individuals in underserved areas. The current study sought to describe the mental health care services delivered by providers perceived as affirming by TGNC community members in the Central Great Plains. We conducted qualitative interviews with 10 providers to understand how providers seek cultural competency and conceptualize and work with their TGNC clients given the barriers to care. Providers held diverse theoretical orientations and described challenges to working with TGNC clients, including the impact of stigma and marginalization and financial and structural barriers to care. Emphasis was placed on individualizing care, helping clients to manage stigma and build resiliency, connecting clients to resources (when available) and support systems, and navigating the intersections of physical health care and mental health care, such as writing letters for medical transition. Providers largely educated themselves on TGNC topics and had previous experience working with marginalized populations. Overall, the providers' approaches to working with TGNC clients mapped onto models of cultural competency, but few providers described their work in the context of an evidence-based model. Implications for increasing the quality and availability of mental health care services for TGNC individuals in underserved areas are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Bone Densitometry in Transgender and Gender Non-Conforming (TGNC) Individuals: 2019 ISCD Official Position

Adverse childhood experiences (ACEs) are critical determinants of long-term psychological and physiological health outcomes. Transgender and gender nonconforming (TGNC) individuals are at increased risk for ACEs, including family rejection, peer victimization, and systemic discrimination. Despite the growing body of research on this topic, an updated synthesis of recent literature is needed to understand the evolving landscape of ACE-related risks and protective factors in TGNC populations. This systematic review, conducted according to PRISMA guidelines, examined studies published between 2020 and 2024 that were related to the association between ACEs and mental health outcomes in TGNC individuals. A comprehensive database search yielded 6124 articles, 42 of which met the inclusion criteria. Data extraction focused on the type of ACEs reported, associated mental health outcomes, resilience factors, and clinical implications. The results showed that TGNC individuals are significantly more likely to experience childhood maltreatment, including emotional, physical, and sexual abuse, as well as transphobia-specific ACEs such as forced gender conformity and identity denial. These experiences are associated with an increased risk of depression, PTSD, suicidality, and substance use disorders. Family rejection was found to be a critical risk factor, while social support, gender-specific care, and self-efficacy showed protective effects. The reviewed studies emphasize the urgent need for trauma-informed and gender-affirming mental health interventions to mitigate the effects of ACEs on TGNC individuals. Limitations and future research directions are discussed.

Transgender and gender non-conforming (TGNC) individuals face significant health disparities despite growing visibility and awareness. Nutrition-related disparities are particularly concerning, with TGNC individuals experiencing higher rates of food insecurity, eating disorders, body dissatisfaction, and overweight or obesity. Gender-affirming hormone therapy (GAHT) and other medical interventions lead to significant physiological changes that can influence nutritional needs, as well as body composition and bone mineral density, yet existing daily energy estimation equations do not account for TGNC individuals or those undergoing GAHT. Perioperative nutrition is also vital, as gender-affirming surgeries increase metabolic demands and risk of muscle loss due to immobility and catabolism. Moreover, TGNC individuals report higher rates of food insecurity, with transgender men being particularly affected, largely due to economic disparities and systemic discrimination. Eating disorders are likely under reported in this population due to limited access to competent, inclusive care. Most research combines transgender and gender non-conforming individuals, limiting insight into subgroup differences. To improve health outcomes among TGNC individuals, there is a critical need for more inclusive, longitudinal research, particularly in the areas of nutrition, metabolism, and post-surgical care. Such research could inform the development of tailored interventions, enhance healthcare provider competence, and support the creation of clinical guidelines that address the specific health and nutrition needs of TGNC individuals. Ultimately, this would help reduce disparities and promote long-term well-being for TGNC individuals.

Drawing from the existing literature on minority stress and stigma, this article highlights challenges – psychological, social, and interpersonal – confronting transgender and gender nonconforming (TGNC) individuals in relation to their gender identity and expression. TGNC individuals are at risk for poor health due to societal stigma and stressors they face as a gender minority group. Further, TGNC individuals may experience stigma in different shapes and forms; specifically, stigma may occur as enacted, felt, internalized, and anticipated stigma. In maintaining an identity that is socially devalued but often invisible to others, TGNC individuals confront additional challenges in negotiating the risks and benefits of disclosing their stigmatized identity. Affirmative group therapy is proposed as a strength-based and social justice–oriented approach for demarginalizing TGNC individuals’ stigmatized identity. Group therapists are called on to address how forms of stigma impact TGNC individuals within and outside of the group, provide validation and space for practicing disclosure, highlight their strengths and resilience, and serve as social justice advocates.

Converging evidence indicates transgender and gender non-conforming (TGNC) individuals generally experience poorer health than their cisgender counterparts. Less is known about TGNC health across gender identity subgroups. Extant work has yielded mixed findings, precluding conclusions regarding the comparative health of transgender women, transgender men, and gender non-conforming individuals. Additionally, this work is limited methodologically, e.g., utilizing convenience samples and operationalizing “transgender” differently across studies. This study aims to improve upon these limitations, and more broadly add to the literature on within-group health differences among TGNC individuals. We used 2016 U.S. population-level data (N = 1,117), conducting MANCOVA (multivariate analysis of covariance) and logistic regression to compare the health of transgender women, transgender men, and GNC individuals. Health outcomes of mental and physical health, substance use, and healthcare access/utilization were selected based on empirical and theoretical support for their relevance to TGNC health. We also completed interaction analyses to test the intersectional effects on health of gender identity and emergent sociodemographic variables, e.g. race/ethnicity. Across TGNC subgroups, individuals reported similar alcohol use, mental health, and healthcare access/utilization. Transgender men reported worse physical health than their counterparts, and GNC individuals reported lower smoking prevalence than their counterparts. Interaction analyses by race/ethnicity indicated Hispanic transgender women reported worse physical health than other Hispanic TGNC individuals, while Black transgender men, Multiracial GNC individuals, and Hispanic transgender women reported worse mental health than some of their intra-racial/ethnic TGNC counterparts. Findings add to the growing literature on TGNC health and highlight TGNC subgroups that may be vulnerable regarding mental and physical health.

Younger adults in China who are transgender and gender nonconforming (TGNC) and lesbian, gay, and bisexual (LGB) experience high levels of minority stress (eg, stigma and bullying) and adverse mental health symptoms. However, there is a lack of research documenting mental health disparities compared with their cisgender and heterosexual peers. Studies that disaggregate TGNC and LGB individuals and are conducted in nonmetropolitan regions are also needed. To examine whether younger adult students' psychiatric symptoms and suicide risk vary by sexual orientation and gender identity and identify risk factors within LGB younger adults and TGNC younger adults. This cross-sectional study surveyed students at 63 universities in Jilin Province, China, between October 24 and November 18, 2021. Analyses were completed May 6, 2022. Gender identity (TGNC vs cisgender) and sexual orientation (LGB vs heterosexual). Psychiatric outcomes included depression, anxiety, traumatic stress, and nonsuicidal self-injury (NSSI), which were measured by the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Trauma Screening Questionnaire, and self-reported NSSI behaviors. The Suicide Behaviors Questionnaire-Revised was used to assess suicide risk. The analytic sample included 89 342 younger adults (mean [SD] age, 19.60 [1.75] years), including 51 438 assigned female at birth and 37 904 assigned male at birth. The sample included 2352 individuals who were TGNC, 6501 who were cisgender LGB, and 80 489 who were cisgender heterosexual. Compared with their cisgender heterosexual peers, TGNC and LGB younger adults were more likely to experience increased psychiatric symptoms across categories and suicide risk, as well as more severe forms of symptoms. In particular, overall suicide risk was 43.03% among TGNC individuals, 36.21% among LGB individuals, and 11.70% among cisgender heterosexual younger adults. Controlling for demographic variables and compared with cisgender heterosexual peers, TGNC young adults had higher odds of suicide risk (adjusted odds ratio, 5.38; 95% CI, 4.94-5.86; P < .001) and of past-year NSSI (adjusted odds ratio, 6.55; 95% CI, 5.87-7.30; P < .001). Separate within-group analyses for LGB and TGNC younger adults highlighted the vulnerability of bisexual women and gender nonbinary groups, as well as the relevance of minority stress-related risk factors, including peer bullying and assault and loneliness. This study noted disparities of mental health issues among LGB, transgender, or queer or questioning younger adults in China and suggests a high urgency to address psychological health and prevent suicide in this population. Targeted public health initiatives may be needed to reduce stigma and discrimination, train competent health care professionals, and create affirmative mental health policies and systems of care.

Study question To explore whether transgender and gender-nonconforming (TGNC) individuals are offered counselling on their fertility preservation options, and their levels of decisional regret on this matter. Summary answer TGNC individuals are still not systematically offered counselling on their fertility preservation options before initiating gender-affirming hormone therapy (GAHT), and the majority experiences regret. What is known already Although cross-sex hormones have been known to impact reproduction capacity, the extent and reversibility of this effect are still unclear. Guidelines recommend that all TGNC individuals receive counselling on their fertility preservation options before starting GAHT and periodically thereafter. Evidence regarding counselling implementation and quality is scarce, and there is even less knowledge about decision regret concerning this matter in the TGNC population. Study design, size, duration We present a single-centre, spontaneous, cross-sectional study, which will last until mid-May 2025. Our aim is to enroll at least 500 participants from all over Italy, which is an adequate size (Confidence Interval 95%, margin of error 5%) considering the estimates on the numerosity of the Italian TGNC populations (0,3% of the general adult population, corresponding to approximately 177000 individuals). The study is ongoing, and this is an interim report. Participants/materials, setting, methods Participants include all TGNC individuals residing within the Italian territory. We disseminated a survey online, consisting of two sections: first, an ad hoc questionnaire investigating participants’ demographics, their attitudes towards fertility and specificities of the fertility preservation process, and, secondly, the Decision Regret Scale. Data were collected anonymously, and subsequently analysed. Main results and the role of chance As of now, 102 participants have completed the questionnaire, including 36 AMAB and 66 AFAB TGNC individuals. 96 (94.1%) completed the counseling section prior to GAHT initiation. Of these, 51 (53.1%) reported having received counseling, 33 (34.1%) did not receive any counseling, and 12 (12.5%) did not remember. Among those who received counseling, 19 (37.3%) considered it adequate or very adequate, while 8 (15.7%) considered it inadequate. The remainder (47.1%) classified it as neutral. Among individuals who received counseling, three individuals (5.9%) had undergone fertility preservation treatment, of which one displayed regret for a moderate outcome. In individuals who did not undergo fertility preservation treatment, no regret was reported by 13 (28.3%), moderate regret levels were reported by 14 (30.4%), and high regret was reported by 19 (41,3%) participants. In the group that did not receive counseling, no one underwent any fertility preservation treatment. Regret was absent in 6 (22.2%), moderate in 11 (40.7%), and high in 10 (37%) individuals (P &amp;gt; 0.05 counseling vs no counseling group). Limitations, reasons for caution Findings are preliminary, and more data needs to be gathered before drawing conclusions. In addition, the complete anonymity of the survey does not guarantee that participants are in fact TGNC individuals. Wider implications of the findings More needs to be done to ensure that all TGNC individuals receive adequate information on their fertility preservation options, both by implementing systematic counselling and by improving its adequacy. This would empower TGNC individuals to make informed choices on one of their fundamental human rights. Trial registration number No

Rural living environment predicts social anxiety in transgender and gender nonconforming individuals across Canada and the United States

ABSTRACTBackground: When accessing mental healthcare services, transgender and gender nonconforming (TGNC) individuals face systemic barriers to gender-affirmative care. Initial points of contact, like intake forms, may show limited consideration for the heterogeneity of TGNC identities and can lead to negative consequences prior to face-to-face interaction with providers. Aims: The first aim was to mimic a likely pathway a TGNC individual may follow to seek mental healthcare services in the USA and to describe the extent to which they may encounter enacted stigma or affirmative messages that may impede or facilitate access to care. The second aim was to determine if a positive State legal climate for TGNC people was associated with more affirmative provider materials. Methods: Content analysis was used to examine a national sample of websites and intake forms of mental healthcare providers who advertise online as working with TGNC clients. Intake forms were coded for usage of affirmative language in gender/sex questions and including questions for a client's pronouns and preferred name. Websites were coded for mentioning a variety of services or resources for TGNC clients. Results: While provider websites were found through Google searches for a “gender therapist,” only 56.6% of websites stated a provider specialty to work with TGNC clients and 32.1% of websites had no mention of services or resources for TGNC people. Additionally, a significantly larger proportion of intake forms from States with legal protections for TGNC people used affirmative language in gender/sex questions and asked for a client's pronouns than intake forms from States without legal protections. Discussion: Barriers to affirmative healthcare for TGNC people within patient and provider interactions have been identified in previous research and these data show TGNC individuals may face enacted stigma even in their search for a provider, particularly those TGNC people living in States without legal protections.

BackgroundTransgender individuals in India experience immense psychosocial stressors, stigma, and violence. In response to stress, the body exhibits adaptive responses that necessitate the production of organic chemicals ensuing in the detection of blood serum and saliva. There are currently no laboratory tests that are confirmatory for the diagnosis of stress and facilitate necessary treatment to be carried out in a timely manner. Thus, potential salivary biomarkers could be a helpful tool in overseeing the efficacy of pharmacological treatment prescribed by a psychiatrist.AimThis study aimed to assess the correlation between perceived stress and salivary stress biomarker levels in transgender and gender nonconforming (TGNC) individuals in Chennai, India.MethodologyTwenty-two TGNC individuals and 22 age-matched controls in Chennai were administered the Perceived Stress Scale-10 questionnaire. Following this, their saliva samples were collected using the passive drool technique and subjected to sandwich enzyme-linked immunosorbent assay (ELISA) technique for measuring salivary cortisol, salivary tumor necrosis factor-alpha (TNF-alpha), and salivary C-reactive protein (CRP). Independent t-test was used to compare salivary stress biomarker levels between the TGNC and age-matched control groups. Pearson’s correlation test was done to correlate perceived stress and salivary stress biomarker levels in the TGNC group.ResultsSignificant difference was seen between the TGNC and control groups with respect to salivary cortisol and salivary TNF-alpha levels, with the levels being higher in the TGNC group. A significant positive correlation was seen between perceived stress and salivary cortisol and between perceived stress and salivary TNF-alpha levels.ConclusionThere is a significant correlation between perceived stress and salivary biomarkers of stress among TGNC people in Chennai.

Transgender and gender nonconforming (TGNC) individuals face negative consequences linked to prejudice, including homelessness and violence. One medium that perpetuates prejudice toward TGNC individuals is our choice in language. Biased language is related to prejudiced attitudes. Use of gender-inclusive language, however, promotes gender equality. Previous research has examined gender-inclusive language use regarding cisgender men and women, but little work has focused on gender-inclusive language use regarding TGNC individuals. Two studies explored the connections between attitudes toward transgender individuals and perceptions of TGNC-inclusive language. Three hierarchical linear regressions and a mini meta-analysis were conducted. Results suggest that people with negative attitudes toward transgender individuals perceive greater difficulty in using gender-inclusive language. These findings suggest that inclusive language use may be indicative of more positive attitudes.

Transgender and gender non-conforming (TGNC) individuals face high levels of discrimination and mistreatment, including within social and medical service settings, which may lead to negative health and psychosocial sequelae. Given the many barriers to competent care, we sought to determine points of intervention by assessing the current needs, satisfaction, and health care utilization of TGNC individuals in New York City as reported by TGNC individuals. In January 2013, fifty TGNC individuals were recruited via flyers and direct referrals from healthcare professionals within community spaces and pertinent venues. We administered a brief survey and conducted four focus groups exploring participants' health care utilization and perceived barriers to care, routine care, hormone and silicone use, and recommendations for improving transgender services. Participants were 18- to 64-years-old, racially/ethnically diverse, and the majority were medically insured, underwent routine health care in the last year, and received an HIV test in their lifetime. A significant proportion reported taking hormones prescribed by a medical provider and were in the care of knowledgeable providers. Participants perceived four areas where barriers persisted: utilization of preventive services, access to transition-related procedures, access to legal assistance, and inclusion of TGNC individuals in public health education and campaigns. Structural interventions are needed, such as comprehensive provider training programs for all level staff to better serve the needs of TGNC individuals, increase service utilization and improve wellbeing, while effecting lasting institutional change. Service provision establishments should hire more TGNC staff and integrate transgender care into existing practices.

Transgender and gender nonconforming (TGNC) individuals experience increased risk to mental and physical health concerns based on minority stress variables, including discrimination, internalized stigma, and expectations of violence. Research in this area displays a disconnect between provider and TGNC individuals seeking care. This study sought to improve cultural competency in research with TGNC individuals, with the ultimate goal to further explore cultural competency factors in work with TGNC individuals in research and clinically. Mixed methods research was conducted with trans masculine, trans feminine, and nonbinary identifying individuals to pilot survey measures before administration in a larger study.