Gender-expansive People Research Articles

Advancing feminist innovation in sport studies: A transdisciplinary dialogue on gender, health and wellbeing.

Athlete health and wellbeing requires a holistic, multidimensional approach to understanding, supporting, and treating individual athletes. Building more supportive, inclusive, and equitable environments for the health and wellbeing of women and gender expansive people further requires gender-responsive approaches that promote broader cultural change. Feminist sport and exercise medicine practitioners, sports scientists, and social science researchers are increasingly coming together in their efforts to do this work. However, working across disciplines inevitably includes an array of ontological, epistemological, and political challenges. In this paper, we offer a curated 'dialogue' with a group of feminist scholars engaged in research and practice across disciplines, bringing them together to discuss some of the most pressing gendered issues in sport today (i.e., ACL injury, concussion, menstruation in sport, mental health, gender categories). In so doing, we amplify the voices of those working (empirically and clinically) at the disciplinary intersections of gender, sport and health, and learn about some of the current and future possibilities for transdisciplinary innovations and strategies for building (responsiveness to) cultural change.

Introduction to the Special Issue on Feminist Therapy with Transgender, Nonbinary, and Gender Expansive People

Transgender, nonbinary, and gender expansive (TNBGE) people have been historically excluded from feminist approaches broadly, including in the realm of therapy. This special issue examines the utility of feminist therapy with TNBGE people, along with its potential and limitations. Contributors focus on specific issues affecting TNBGE people, such as migration and citizenship status, sexual well-being, trauma and violence, neurodiversity, and developmental context. Feminist approaches are explored using intersectional and strengths-based lenses in a diversity of clinical settings and across various aspects of the therapeutic process with TNBGE people.

Healthcare Mistreatment, State-Level Policy Protections, and Healthcare Avoidance Among Gender Minority People

IntroductionThis study examined whether past experiences of mistreatment in healthcare were associated with greater healthcare avoidance due to anticipated mistreatment among gender minority (GM) people. We evaluated whether state-level healthcare policy protections moderated this relationship.MethodsData from the 2018 Annual Questionnaire of The PRIDE Study, a national longitudinal study on sexual and gender minority people’s health, were used in these analyses. Logistic regression modeling tested relationships between lifetime healthcare mistreatment due to gender identity or expression and past-year healthcare avoidance due to anticipated mistreatment among GM participants. Interactions between lifetime healthcare mistreatment and state-level healthcare policy protections and their relationship with past-year healthcare avoidance were tested.ResultsParticipants reporting any lifetime healthcare mistreatment had greater odds of past-year healthcare avoidance due to anticipated mistreatment among gender expansive people (n = 1290, OR = 4.71 [CI]: 3.57–6.20), transfeminine people (n = 263, OR = 10.32 [CI]: 4.72–22.59), and transmasculine people (n = 471, OR = 3.90 [CI]: 2.50–6.13). Presence of state-level healthcare policy protections did not moderate this relationship in any study groups.ConclusionsFor GM people, reporting lifetime healthcare mistreatment was associated with healthcare avoidance due to anticipated mistreatment. State-level healthcare policy protections were not a moderating factor in this relationship. Efforts to evaluate the implementation and enforcement of state-level policies are needed. Continued efforts to understand instances of and to diminish healthcare mistreatment of GM people are recommended.

Psychometric evaluation of the muscle dysmorphic disorder inventory (MDDI) among gender-expansive people

PurposeMuscle dysmorphia is generally classified as a specific form of body dysmorphic disorder characterized by a pathological drive for muscularity and the preoccupation that one is too small or not sufficiently muscular. The majority of research on the condition has been conducted in cisgender men with a paucity of literature on gender minority people, a population that is at risk for muscle dysmorphia. One of the most widely used measures of muscle dysmorphia symptoms, the Muscle Dysmorphic Disorder Inventory (MDDI), has not been psychometrically validated for use in gender minority samples, the aim of the present study.MethodsWe evaluated the psychometric properties of the MDDI in a sample of 1031 gender-expansive individuals (gender minority people whose gender identity differs from that assumed for their sex assigned at birth and is not exclusively binary man or woman) aged 18–74 who were part of The PRIDE Study, a large-scale, U.S., longitudinal cohort study.ResultsUsing a two-step, split-sample exploratory and confirmatory factor analytic approach, we found support for the original three-factor structure of the measure. The subscales showed adequate internal consistency, and convergent validity was supported based on significant associations of the MDDI subscale scores with theoretically related scores on a widely used measure of disordered eating.ConclusionsThese findings provided novel support for adequate psychometric properties of the MDDI in a sample of gender-expansive individuals, facilitating the use of this measure in future research on muscle dysmorphia in this understudied and at-risk population.

Destigmatizing and Democratizing Postpartum Care: A "Black Woman-Person First" Approach.

Optimizing postpartum care highlights the need for care coordination, enhancement, and expansion of health care services after childbirth. Yet the prioritization of disease surveillance, management, and mitigation during birth and beyond within the American College of Obstetrics and Gynecology facilitates the medicalization and pathologization of Black bodies, voices, and power. Thus, we offer the Building and Bridging Black Futures Beyond Birth Model: A 12-Step Black Woman-Person First Approach, as a more humane and holistic model of culturally affirming and clinically responsive care. Destigmatizing and democratizing care bridges the gap between intent and impact in postpartum care optimization, particularly for Black women, girls, and gender expansive people and their communities.

The Cost of Visibility: Minority Stress, Sexual Assault, and Traumatic Stress among Bisexual Women and Gender Expansive People

Utilizing minority stress framework, this study assessed a model examining the mechanisms associated with bisexual women’s and gender expansive peoples’ experiences of sexual assault and PTSD symptoms. A total of 378 bisexual women and gender expansive people participated in this study, with the majority of participants identifying as White, cisgender women. Findings revealed that higher levels of outness were positively associated with more frequent anti-bisexual discrimination. In addition, anti-bisexual discrimination and sexual assault were significantly positively related to greater PTSD symptoms. Anti-bisexual discrimination was uniquely positively associated with more frequent experiences of sexual assault, and outness was indirectly related to sexual assault through anti-bisexual discrimination. Moreover, anti-bisexual discrimination was indirectly related to PTSD symptoms through sexual assault. Suggestions for future research and practice implications are discussed.

Appearance and performance‐enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people

ObjectiveAppearance and performance‐enhancing drugs and supplements (APEDS) can be used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among gender minority people.MethodParticipants were 1653 gender minority individuals (1120 gender‐expansive [defined as a broad range of gender identities that are generally situated outside of the woman–man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.ResultsLifetime APEDS use was common across groups (30.7% of gender‐expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender‐expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender‐expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.DiscussionAPEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender‐expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.Public SignificanceThis study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender‐expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender‐expansive people. Clinicians should assess for these behaviors in gender minority populations.

Social Work Education & Support of Gender Expansive People: A Qualitative Analysis of MSW Student Experiences

ABSTRACT This study examined Master of Social Work (MSW) student experiences with social work education related to support of transgender, nonbinary, queer or other gender expansive people. Sixty-seven students from a sample of thirty-four MSW programs in the United States provided brief qualitative reflections on their educational experiences related to gender identity or expression. Thematic content analysis of these data revealed five primary emergent themes related to; MSW program capacity, persistent bias/tension, safety issues, emotional and academic burden, and lived-experiences external to social work education. Findings suggest there remains a disconnect between the stated intent of social work to support gender expansive communities and the reality of social work education. Specifically, although most students appear to want more from their schools of social work regarding trans-affirming education, most programs reflect persistent discomfort with this domain, or a hesitance or inability to address the topic appropriately and consistently. Examples of how social work education might work to improve its capacity to reflect support of gender expansive people and communities are discussed.

Reconceiving Reproductive Health Systems: Caring for Trans, Nonbinary, and Gender-Expansive People During Pregnancy and Childbirth.

This article examines the barriers to quality health care for transgender, nonbinary, and gender-expansive people (TGE) who become pregnant and give birth, identifying three central themes that emerge from the literature. These insights suggest that significant reform will be necessary to ensure access to safe, appropriate, gender-affirming care for childbearing TGE people. After illustrating the need for systemic changes that untether rigid gender norms from the provision of perinatal care, the article proposes that the Midwives Model of Care offers a set of values and clinical practices that are well-suited to meet the needs of many TGE patients during pregnancy and childbirth and which should be incorporated into the healthcare system more broadly.

INTRODUCTION.

I am pleased to introduce this Symposium Edition of The Journal of Law, Medicine & Ethics, which covers a wide variety of issues central to transgender health equity, including Dr. Jamison Green's recent history of the impact of health policy on transgender communities, Dr. M. Killian Kinney, Ms. Taylor Pearson, and Prof. Julie Ralston Aoki's transgender equity tool for legal policy analysis, and Prof. Elizabeth Kukura's analysis of issues facing transgender, non-binary, and gender expansive people during pregnancy and childbirth.

The Never-Ending Struggle for Reproductive Rights

For me, the annual Book Review issue is a time for reflection. It provides an opportunity to take stock of scholarly trends, reassess conventional wisdom, and gather new insights to apply to the practice of law. The reviews contained in this year’s issue address a wide range of subjects, including the history of public defenders, the use of bigotry rhetoric in conflicts over marriage and civil rights law, the role of cost-benefit analysis in federal policymaking, and racial inequities in tax policy. This impressive commentary on an astute and varied collection of books about the law will inspire many of us to pause and consider larger questions about our own work: Where do things stand? How did we get here? What comes next? My career has largely focused on reproductive rights. It is an area of the law that is perpetually at a crossroads and therefore always ripe for reflection. These rights, long recognized and deeply valued by a majority of Americans, are continually under attack and always—it would seem—on the brink of elimination. Almost from the day Roe v. Wade was decided, critics began calling for it to be overruled, and commentators began predicting its downfall. Although it has weathered the storm for nearly fifty years, those critics and commentators remain undeterred, still forecasting Roe’s imminent demise. And who knows? Perhaps this charged moment in our nation’s history, which seems increasingly like the dystopian future that prescient novelists warned of long ago, will see a disruption in constitutional protection for reproductive rights. Or perhaps the rights that have been central to the liberty and equality of women and gender-expansive people for half a century will continue to endure. In this Foreword, I would like to reflect on two aspects of reproductive rights law in particular. First, there is a seeming duality in the Supreme Court’s abortion jurisprudence. On the surface, it embodies a longstanding commitment to safeguarding the right to abortion. But just below the surface, the caselaw reflects a deep tension between this commitment and the Court’s recognition that certain members of our society—some motivated by “unprincipled emotional reactions” and others motivated by “principles worthy of profound respect”—will never accept that the Constitution grants the authority to make decisions about the outcome of a pregnancy to the individual who is pregnant rather than to the government. Second, the abortion right has proven surprisingly durable despite powerful efforts to subvert it. It seems that the vital relationship of this right to core constitutional values like liberty, equality, and freedom of belief, and the critical role that it plays in the ability of women and all people with the capacity for pregnancy to participate fully and equally in society, make it extremely difficult to cast aside, rhetorical denunciations notwithstanding.

Global scoping review of HIV prevention research with transgender people: Transcending from trans-subsumed to trans-centred research.

IntroductionGlobally, transgender populations are disproportionally impacted by HIV and effective HIV prevention interventions targeting these populations are critically needed. Such interventions require research focused on the specific needs and experiences of transgender people. This methodological review aims to determine the extent to which HIV prevention research has included transgender participants by subsuming them into non‐transgender populations, or by centring them either in comparison with other groups or as the sole focus of research.MethodsWe searched five electronic databases (e.g. SCOPUS) for empirical studies that focused on HIV prevention and included transgender participants, published through 31 December 2020. For each study, we extracted information on: (a) types of inclusion of transgender participants; (b) total sample size and number/percentage of transgender participants; (c) country(ies) where study was conducted; (d) HIV research topics; (e) methods (i.e. quantitative, qualitative or mixed‐methods research) and (f) gender identity of transgender participants.Results and discussionOf 667 HIV prevention studies included in the review, 38.5% subsumed transgender participants into cisgender populations (most frequently combining transgender women with cisgender men who have sex with men), 20.4% compared transgender and cisgender participants and 41.1% focused exclusively on transgender populations. Our global scoping review also revealed that these three types of transgender inclusion in HIV prevention research vary greatly over time, place and thematic areas. Transgender women are the focus of the majority of reviewed studies, whereas transgender men and gender expansive people are rarely included as participants.ConclusionsInclusion of transgender persons as participants in HIV prevention research has significantly increased, particularly in the last decade. Further research centred on transgender participants and their experiences are needed to develop effective HIV prevention interventions for transgender populations. We advocate for HIV prevention research to move from subsuming transgender people, to trans‐centred research that asks questions that focus on their specific needs and experiences. We provide recommendations to move from trans‐subsumed to trans‐centred HIV prevention research.

Community norms of the Muscle Dysmorphic Disorder Inventory (MDDI) among gender minority populations

PurposeRepresenting the pathological extreme pursuit of muscularity, muscle dysmorphia (MD) is characterized by a pervasive belief or fear around insufficient muscularity and an elevated drive for muscularity. Despite evidence of heightened body image-related concerns among gender minority populations, little is known about the degree of MD symptoms among gender minorities, particularly based on Muscle Dysmorphic Disorder Inventory (MDDI) scores. The objective of this study was to assess community norms of the MDDI in gender-expansive people, transgender men, and transgender women.MethodData from participants in The PRIDE Study, an existing study of health outcomes in sexual and gender minority people, were examined. We calculated means, standard deviations, and percentiles for the MDDI total and subscale scores among gender-expansive people (i.e., those who identify outside of the binary system of man or woman; n = 1023), transgender men (n = 326), and transgender women (n = 177). The Kruskal-Wallis test was used to assess group differences and post hoc Dunn’s tests were used to examine pairwise differences.ResultsTransgender men reported the highest mean MDDI total score (30.5 ± 7.5), followed by gender-expansive people (27.2 ± 6.7), then transgender women (24.6 ± 5.7). The differences in total MDDI score were driven largely by the Drive for Size subscale and, to a lesser extent, the Functional Impairment subscale. There were no significant differences in the Appearance Intolerance subscale among the three groups.ConclusionsTransgender men reported higher Drive for Size, Functional Impairment, and Total MDDI scores compared to gender-expansive people and transgender women. These norms provide insights into the experience of MD symptoms among gender minorities and can aid researchers and clinicians in the interpretation of MDDI scores among gender minority populations.

“I Was a Game or a Fetish Object”: Diverse Bisexual Women’s Sexual Assault Experiences and Effects on Bisexual Identity

Utilizing minority stress theory and intersectionality framework, this qualitative content analysis explored sexual assault experiences among 532 diverse bisexual women and gender expansive people. Findings revealed that many participants attributed their experiences of sexual assault to binegativity, which manifested as hypersexualization, “corrective rape,” perpetrator insecurity, and interpersonal hostility. In addition, participants described intersections between binegativity and other forms of oppression, including gendered racism, gendered binegativity, ableism, sizeism, and classism, and shared how they believed that these intersecting forms of oppression made them more vulnerable to sexual assault. Participants also described the ways in which sexual assault affected their understanding of and experience with their bisexual identity. For example, many participants expressed a number of relational and sexual affects (e.g., greater caution when entering into relationships with people of a certain gender, sexual discomfort, decreased sexual agency) and effects on their bisexual identity (e.g., identity disclosure process, questions about multiple aspects of their identities). Suggestions for future research and practice implications are discussed.

Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

BackgroundTransgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.MethodsIn 2019, we recruited participants for an online survey about sexual and reproductive...

Crafting New Narratives of Diasporic Resistance with Indo-Caribbean Women and Gender-Expansive People across Generations

This study used participatory oral history and digital archiving to explore two interrelated questions: How do Indo-Caribbean women and gender-expansive people across generations experience processes of storytelling? What are the challenges and possibilities of oral history and digital archiving for constructing alternative histories and genealogies of resistance? In the first phase of the study, twelve Indo-Caribbean women and gender-expansive people across generations participated in an oral history workshop where they were introduced to oral history methods, co-created an interview guide, conducted oral history interviews of one another, and engaged in collective reflection about processes of storytelling. In the second phase, four co-authors of a community-owned digital archive participated in semi-structured interviews about their work to craft new narratives of diasporic resistance rooted in the everyday stories of Indo-Caribbean women and gender-expansive people. In this paper, I analyze how Indo-Caribbean women and gender-expansive people practice resistance by breaking silences in their communities around gender-based oppression, shift norms through producing analyses of their own stories, and reshape community narratives. Furthermore, I explore how oral history participants and co-authors of a digital archive understand the risks associated with sharing stories, raising the ethical dilemmas associated with conceptualizing storytelling as purely liberatory.

Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: Results from a national, quantitative survey

Background: Transgender, nonbinary, and gender-expansive (TGE) people experience pregnancy. Quantitative data about pregnancy intentions and outcomes of TGE people are needed to identify patterns in pregnancy intentions and outcomes and to inform clinicians how best to provide gender-affirming and competent pregnancy care. Aims: We sought to collect data on pregnancy intentions and outcomes among TGE people assigned female or intersex at birth in the United States. Methods: Collaboratively with a study-specific community advisory team, we designed a customizable, online survey to measure sexual and reproductive health experiences among TGE people. Eligible participants included survey respondents who identified as a man or within the umbrella of transgender, nonbinary, or gender-expansive identities; were 18 years or older; able to complete an electronic survey in English; lived in the United States; and were assigned female or intersex at birth. Participants were recruited through The PRIDE Study – a national, online, longitudinal cohort study of sexual and gender minority people – and externally via online social media postings, TGE community e-mail distribution lists, in-person TGE community events, and academic and community conferences. We conducted descriptive analyses of pregnancy-related outcomes and report frequencies overall and by racial and ethnic identity, pregnancy intention, or testosterone use. Results: Out of 1,694 eligible TGE respondents who provided reproductive history data, 210 (12%) had been pregnant. Of these, 115 (55%) had one prior pregnancy, 47 (22%) had two prior pregnancies, and 48 (23%) had three or more prior pregnancies. Of the 433 pregnancies, 169 (39%) resulted in live birth, 142 (33%) miscarried, 92 (21%) ended in abortion, two (0.5%) ended in stillbirth, two (0.5%) had an ectopic pregnancy, and seven (2%) were still pregnant; nineteen pregnancies (4%) had an unknown outcome. Among live births, 39 (23%) were delivered via cesarean section. Across all pregnancies, 233 (54%) were unintended. Fifteen pregnancies occurred after initiation of testosterone, and four pregnancies occurred while taking testosterone. Among all participants, 186 (11%) wanted a future pregnancy, and 275 (16%) were unsure; 182 (11%) felt “at risk” for an unintended pregnancy. Discussion: TGE people in the United States plan for pregnancy, experience pregnancy (intended and unintended) and all pregnancy outcomes, and are engaged in family building. Sexual and reproductive health clinicians and counselors should avoid assumptions about pregnancy capacity or intentions based on a patient’s presumed or stated gender or engagement with gender-affirming hormone therapy.

Transgender-Competence in Social Work Education: The Relationship of School Contexts to Student Affirmation of Gender Expansive People

ABSTRACT This study examined the relationship between Master of Social Work program’s (MSW) support of lesbian, gay, bisexual, and transgender people (LGBT-competence), and social work student’s self-perceived competence to support transgender people (transgender-competence). Thirty-four accredited MSW programs in the United States provided a sample of program directors, faculty members, and students (N = 1385). Hierarchical linear models revealed an MSW program’s LGBT-competence was associated with the transgender-competence of its students, and that significant differences exist between organizational LGBT-competence and individual transgender-competence within schools of social work. Specifically, programs with greater LGBT-competence also had students who felt more competent to work with gender minorities. These findings suggest schools of social work provide different levels of support for gender minorities, and that such programs can take substantive action at an organizational level to improve the professional competence of future social workers to serve transgender populations. Implications for social work education are discussed.

O12 Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the united states: Results from a national quantitative survey

Objectives: To elucidate the existing data gaps on the abortion experiences and preferences of transgender and gender expansive (TGE) people.

P13 Experiences of self-managed abortion among transgender, nonbinary, and gender expansive people in the US

Objectives: To describe the self-managed abortion experiences of transgender, nonbinary, and gender-expansive (TGE) people in the US.