Review of Siri Gullestad’s article transgender – a challenge for psychoanalysis?

Background: Nonbinary people experience marginalization through discrimination, rejection, microaggressions, and stigma as a result of not always conforming to societal gender norms embedded in the gender binary. There is limited research about how nonbinary Black, Indigenous, and People of Color (BIPOC) living in the United States navigate societally enforced binary gender norms, which is especially important to understand given how racism and Euro-colonization have enforced the gender binary. Better understanding the internal strategies nonbinary people use to cope, embody affirmation, and regulate emotions in response to marginalizing experiences could increase understanding of how to best prevent and address the health disparities experienced by nonbinary people. Aim: Drawing on the practices of interrogating norms central to queer theory with a sensitization to racism and settler colonialism, this study aimed to identify a framework to understand nonbinary peoples’ processes of navigating gender norms internally through their lived experiences with an awareness of how context impacts these processes. Method: This qualitative interview study utilized construcitivist grounded theory methodology, guided by queer theory. Twenty-one nonbinary individuals were interviewed over Zoom with 15 being BIPOC. Results: Participants navigated binary gender norms internally by self-defining affirmative nonbinary ways of being, noticing affirmation in a chosen community that allowed them to experience existing authentically outside of binary gender norms, and internally connecting to an embodied, authentic sense of gender within themselves and in community with other nonbinary people. These internal processes were influenced by two contextual factors: societal and cultural expectations of gender; and the contextual impacts of holding multiple marginalized identities. Discussion: Understanding the contexts of the gender binary, racism, and cissexism that impact nonbinary people on a daily basis is crucial for mental health professionals, researchers, policy makers, and creators of gender inclusive education and support programs to support and affirm nonbinary people.

Insights from outside BJOG

Setting out advice, research and personal reflections to inform professionals’ daily practice and overall understanding of the lives and experiences of autistic transgender and non-binary people, this edited volume is an invaluable resource for anyone who seeks to engage more with autistic transgender, non-binary or gender-variant people. Aiming to contextualise the overlap of autism and gender variance, this book features chapters by leading authorities such as Wenn Lawson, Damian Milton, Isabelle Hénault, Reubs Walsh, Lydia X. Z. Brown, and Shain Neumeier as well as other contributors from around the world. The collection is structured in three sections; the first provides interdisciplinary and intersectional approaches on autism and gender as well as the experiences of transgender and non-binary autistic people; the second features professionals discussing their work, the challenges they face and the solutions they find helpful; and the final section presents thoughts and perspectives from trans and non-binary autistic people on various aspects of their experiences, focusing on information that professionals will need to consider and discuss with the people they support. Combining rich and nuanced accounts of the lives of autistic trans people, practical guidance and information as well as the latest academic research about autistic transgender and non-binary individuals, this unique collection is essential reading for any professional wanting to develop their daily practice.

Aims: Mental health support for trans and non-binary people has been under scrutiny for many years. Trans and non-binary people often present to mental health services with co-morbid mental health difficulties. Medical practitioners often report a lack of training and understanding. GPs, psychiatrists and allied health professional frequently request more information to help educate and inform their practice and to support them in offering the best care for their patients and their families and carers.Methods: A small working group was set up by AWP (Avon and Wiltshire Partnership NHS Trust) and SARI (a Bristol-based charitable organisation Stand Against Racism & Equality) with members of the trans and non-binary community in the South West of England. The group’s objectives were to develop novel training for staff and to produce some written guidance that reflected all the evidence-base. This guidance was identified as needing to be for education and guidance only rather than anything prescriptive. It also needed to be easy to read, accessible and available in different formats to reach a wide target audience.Results: The working group was led by the trans and non-binary community and, in collaboration with the AWP, SARI and other health professionals, staff training and a guidance booklet was produced.The training was aimed at providing health professionals with the knowledge and understanding to support gender diverse people that they may meet as patients, colleagues or friends. The training was unique in that it was the first training of its type to be written and delivered by trans and non-binary people. It has been a huge success and the feedback has been consistently outstanding.The written guidance includes a booklet as an education tool for all health professionals. It is for guidance and understanding only rather than anything prescriptive. This was co-written by health professionals and the trans/non-binary community. The guidance includes important information about how to support a trans or non-binary person, common questions and misconceptions, the latest information about trans health care, and the interface with mental health services. This is particularly important in the current political climate where trans and non-binary people are feeling that their health care needs are threatened and that they are feeling increasingly vulnerable. It is important for psychiatrists, GPs and other health professionals to feel confident in supporting gender diverse people who may present to them experiencing significant mental health difficulties. This guidance addresses all the aspects of mental health co-morbidity and how to equip clinicians with the knowledge and skills to provide genuine care.Conclusion: The training has been an enormous success and has attracted attention and positive feedback. Staff report that they now feel equipped with skills to support trans and non-binary people as patients, colleagues or in their personal lives. The fact that the training was delivered by trans and non-binary people has been described as unique and trail-blazing. Members of the trans community are also delighted to feel included and listened to.The guidance booklet: Supporting Trans and Non-Binary People – Best Practice Guidance for Health & Wellbeing Practitioners was launched at various Pride events in the South West and shared with health professionals working in GP surgeries, mental health services and charitable organisations. The guidance itself has been praised widely reflected by a number of awards including AWP staff awards (winner) and the National Diversity Awards (finalist). The guidance has been cited as an essential education and guidance tool. It is updated regularly to reflect service changes and continues to be in high demand. This is something to be celebrated in this current climate where equality, diversity and inclusion remain central in how we support and look after our patients and each other.(Copies of the booklet will be available to take away or can be accessed via the QR code on the day).

Transgender and nonbinary (trans) people can face unique barriers to accessing gender-inclusive perinatal care. The present study explored trans people’s experiences of perinatal care in Aotearoa New Zealand. A thematic analysis of 17 interviews with trans people and their whānau identified seven themes regarding the operation and impact of cisnormativity on participants’ family-building journeys. Findings indicate that cisnormativity manifests as an erasure of gender diversity and creates barriers to affirming and safe care. Importantly, participants’ constant negotiation of cisnormativity in perinatal care had enduring impacts on their well-being. Addressing cisnormativity is fundamental to securing trans reproductive justice.

Understanding the effect of the environment is fundamental to grasping the occupational experiences of nonbinary individuals. Current research in occupational science addresses the occupations of the transgender population but often fails to distinguish between the binary and nonbinary experience. There is an absence of occupational science research that solely focuses on the nonbinary experience. This study focuses on nonbinary individuals and aims to illuminate the environmental factors that support or hinder occupational engagement for nonbinary individuals. Using a descriptive qualitative research design, we conducted two interviews per participant and photo-elicitation. Data analysis resulted in three themes: binary environments and safe spaces, navigating binary spaces through doing gender and avoiding unsafe spaces, and undoing gender through occupation. These themes capture the experience of occupations within the environment for nonbinary people involved doing, being, and becoming nonbinary gender. Each of these responses depended on how safe and welcoming the environment was perceived to be. Our findings illuminate that the process of doing nonbinary gender is a reciprocal relationship between the person, their occupations, and the environment, and support the complex nature of occupation for diverse populations that fall outside the dominant binary culture.

Objective: To examine outcomes from a four-part webinar series on affirming approaches to working with trans and non-binary young people in terms of Australian psychologists’ confidence in working with this population. Method: The author designed and ran a webinar series for the Australian Psychological Society (APS) in early 2018. Of the 76 webinar registrants, 55 completed a survey both before the first webinar, and after completing all of the webinar series. The first survey collected information about demographics, past clinical and training experiences, awareness of the DSM-5 diagnosis of “gender dysphoria”, and confidence in working with trans and non-binary young people. The first survey also included open-ended questions asking participants to define “cisgenderism”, “transgender”, and “non-binary”. The second survey included the same questions and additionally asked about understandings of gender diversity, pathways to care, and awareness of the APS information sheet on affirming approaches. Results: Participants who had previously undertaken training, and previously worked with trans and non-binary people reported greater confidence prior to the webinar series. Statistically significant associations with confidence were found following the webinar series. Greater understanding of gender diversity and the APS information sheet were associated with confidence. Content analysis of the open-ended responses identified improved understandings of the three definitions for most participants after the webinar series. Conclusions: Training for psychologists providing affirming care to trans and non-binary young people is important not only for those who specifically work with this population, but also for generalists, given that many young people may require mental health care beyond that specific to gender transition. KEY POINTS What is already known about this topic: Previous training and experience in working with trans and non-binary adults are related to increased confidence in providing clinical care, Training for healthcare professionals related to trans and non-binary adults results in increased confidence and knowledge, and The evidence base for affirming approaches to clinical care for trans and non-binary young people is in its infancy. What this topic adds: Training for healthcare professionals related to trans and non-binary young people is specifically associated with confidence, Theoretically informed training opportunities are associated with knowledge about terminology pertaining to trans and non-binary young people, and The training of informed knowledgeable generalists working with trans and non-binary young people can usefully supplement existing specialist paediatric gender services.

BackgroundEarly studies have shown a relationship between activities of daily living (ADL) disability and depressive symptoms in older people. However, discussions on the direction of this relationship are insufficient. The study’s objective was to assess the reciprocal relationship between ADL disability and depressive symptoms among middle-aged and older Chinese people.MethodData was collected in four waves of a nationwide survey, the China Health and Retirement Longitudinal Study (CHARLS), which was carried out in 2011, 2013, 2015, and 2018. In total, this study included 4,124 participants aged ≥ 45 years at baseline. A summing score of the eleven items for basic activities of daily living (BADL) and instrumental activities of daily living (IADL) was calculated to indicate the degree of ADL disability. The 10-item Centre for Epidemiological Studies Depression Scale (CESD-10) was adopted to measure depressive symptoms. The reciprocal relationship between ADL disability and depressive symptoms was tested by cross-lagged models.ResultAt baseline, 911 (22.1%) participants were classified as having difficulties with ADL, and the prevalence of depressive symptoms was 34.4% (1,418). Among middle-aged and older people in China, there was a significant reciprocal and longitudinal relationship between ADL disability and depressive symptoms. People who had difficulty with ADL faced a higher risk of depressive symptoms, and those who suffered from depressive symptoms were accompanied by an increase in ADL disability in the following years. The subgroup analysis on age also showed that ADL disability was reciprocally and longitudinally related to depressive symptoms. However, only women showed similar results in the subgroup analysis on gender.ConclusionThis study shows that ADL disability is bi-directionally related to depressive symptoms in middle-aged and older Chinese people over time. The results suggest we should identify ADL disability and bad psychological conditions in time to prevent subsequent mutual damage among middle-aged and older Chinese people, a vulnerable group rising in the future.

Transgender and non-binary (trans) people face unique challenges when considering decision-making about their reproductive futures. These may include navigating gendered parenthood roles and the potential impacts of medical gender affirmation on their fertility. While fertility preservation offers a way of having biologically related children, barriers to accessing these services among trans people have been identified in literature. This qualitative study sought to understand how trans young adults view and experience fertility preservation, in relation to their desire for family and parenthood. Through a thematic analysis of in-depth interviews with 13 trans and non-binary people in Aotearoa New Zealand, we identified four themes: variability in seeking accurate fertility preservation information; the compounding costs of trans reproduction; experiencing and anticipating cisnormativity in reproductive health services; and (re)imagining family. Overall, participants expressed diverse views on fertility preservation, informed by interpersonal and structural factors. Notably, we found discrepancies between uptake of sperm and egg cryopreservation due to public funding disparities, despite participants agreeing services should be offered equitably to all trans people. These structural barriers require further attention in healthcare, policy and community settings when working with trans young adults considering fertility preservation.

Regional autonomy as local independence acceleration policy framework still has not managed to demonstrate achievement, especially in the fiscal aspects. Start from these problems, this research aims: first, examines the relationship between the General Allocation Fund (Dana Alokasi Umum, DAU) and expenditure area consisting of operating expenditure and capital expenditure; the second examines the relationship between revenue local own (Pendapatan Asli Daerah, PAD) and the expenditure area consisting of operating expenditures and expenditures capital. Third, it examines the relationship DAU and PAD; Fourth, it examines whether there is a flypaper on capital expenditure and operating expenditure regency/ cities in Indonesia during the period 2004 to 2013. In line with these objectives in research analysis tool used is the Granger Causality Test and Vector Autoregressive (VAR). The results show: first, DAU and operating expenditures do not have a reciprocal relationship, while the capital expenditure, DAU has a reciprocal relationship with the capital expenditure. Second, revenue and operating expenditures have a reciprocal relationship, so did his relationship with capital expenditure. Third, DAU and PAD do not have a reciprocal relationship, even though it is actually contrary to the practice that occurs in a government in which the determination of the amount of DAU is based on the PAD. Fourth, there is a flypaper in relation DAU, PAD with capital expenditure.

Despite a broadening consensus about the effectiveness of intermittent preventive treatment (IPTp) in preventing the adverse outcomes of malaria during pregnancy, policy change to IPTp was initially limited to East Africa. In West Africa, where the policy change process for the prevention of malaria during pregnancy started much later, IPTp has been taken up swiftly. To describe the factors that contributed to the rapid adoption of policies to prevent malaria during pregnancy in West Africa. Several factors appear to have accelerated the process: (1) recognition of the extent of the problem of malaria during pregnancy and its adverse consequences; (2) a clear, evidence-based program strategy strongly articulated by an important multilateral organization (World Health Organization); (3) subregionally generated evidence to support the proposed strategy; (4) a subregional forum for dissemination of data and discussion regarding the proposed policy changes; (5) widespread availability of the proposed intervention drug (sulfadoxine-pyrimethamine); (6) technical support from reputable and respected institutions in drafting new policies and planning for implementation; (7) donor support for pilot experiences in integrating proposed policy change into a package of preventive services; and (8) financial support for scaling up the proposed interventions.

Background:Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals.Methods:We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes.Results:We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals.Interpretation:Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.

There is a paucity of population health data on the experiences of transgender, non-binary, and other gender minority gay, bisexual, and queer men, and Two-Spirit people in Canada. To address this gap, this article presents a socio-demographic and health profile of trans and non-binary participants from the community-based bilingual 2018 Sex Now Survey. Participants were recruited in-person from Pride festivals in 15 communities to self-complete an anonymous paper-and-pen questionnaire. To be eligible, participants needed to be at least 15 years old, live in Canada, either report a non-heterosexual sexual identity or report sex with a man in the past 5 years, and not report gender identity as a woman. Through community consultations the survey was inclusive of trans men, non-binary people, and Two-Spirit people. Three gender groups (cisgender, transgender, and non-binary) were created, and trans and non-binary participants were compared with their cisgender peers across a variety of demographic, mental health, sexual health, and general health indicators. Odds ratios were calculated to determine initial significance for categorical variables, and adjusted odds ratios were calculated to control for five possible confounders (age, ethnoracial identity, country of birth, sexual identity, and financial strain). Significant differences emerged across all sets of indicators, with many of these findings remaining significant after adjusting for confounding variables, including significantly higher reported rates of mental health challenges and sexual health service barriers for trans and non-binary participants compared to the cisgender group. Trans and non-binary participants were also more likely to be in polyamorous relationships. Collectively, our findings demonstrate that trans and non-binary people experience significant disadvantages compared with cisgender sexual minority men. Improved educational supports and employment protections, access to queer and gender affirming healthcare, and trauma-informed mental health services are needed to improve the health wellbeing of trans and non-binary people in Canada.

There is a paucity of population health data on the experiences of transgender, non-binary, and other gender minority gay, bisexual, and queer men, and Two-Spirit people in Canada. To address this gap, this article presents a socio-demographic and health profile of trans and non-binary participants from the community-based bilingual 2018 Sex Now Survey. Participants were recruited in-person from Pride festivals in 15 communities to self-complete an anonymous paper-and-pen questionnaire. To be eligible, participants needed to be at least 15 years old, live in Canada, either report a non-heterosexual sexual identity or report sex with a man in the past 5 years, and not report gender identity as a woman. Through community consultations the survey was inclusive of trans men, non-binary people, and Two-Spirit people. Three gender groups (cisgender, transgender, and non-binary) were created, and trans and non-binary participants were compared with their cisgender peers across a variety of demographic, mental health, sexual health, and general health indicators. Odds ratios were calculated to determine initial significance for categorical variables, and adjusted odds ratios were calculated to control for five possible confounders (age, ethnoracial identity, country of birth, sexual identity, and financial strain). Significant differences emerged across all sets of indicators, with many of these findings remaining significant after adjusting for confounding variables, including significantly higher reported rates of mental health challenges and sexual health service barriers for trans and non-binary participants compared to the cisgender group. Trans and non-binary participants were also more likely to be in polyamorous relationships. Collectively, our findings demonstrate that trans and non-binary people experience significant disadvantages compared with cisgender sexual minority men. Improved educational supports and employment protections, access to queer and gender affirming healthcare, and trauma-informed mental health services are needed to improve the health wellbeing of trans and non-binary people in Canada.

Scholars are increasingly recognizing that substantial gender heterogeneity exists among transgender populations; that is, gender identities that defy the ubiquitous binary categories of male and female. However, the developing research base on the families of transgender adults focuses almost exclusively on the family members of transgender persons with binary gender identities, a noteworthy shortcoming considering the prevalence of nonbinary gender identities among transgender populations and the pervasive assumption that only two genders exist. To address this gap, the current study sought to uncover how the parents of transgender adults with nonbinary gender identities come to understand, make sense of, and negotiate nonbinary gender identities in their families. Fourteen parents—12 mothers and 2 fathers—completed in‐depth, semi‐structured interviews, and the collected data were analyzed using reflexive thematic analysis. Analyses generated three broad themes that best‐described these parents' experience with their child's gender, which was heavily shaped by the pervasiveness of cisnormativity: (a) varied attempts to understand nonbinary gender; (b) a nonbinary “double‐edged sword”; and (c) familial resilience. Directions for future research, clinical practice, and policy change are discussed, including the therapeutic benefit of dialectical thinking and the need for legislation that legally affirms and protects nonbinary persons.