The Year in Review

The mental health of gender diverse people remains poor compared to that of cisgender people. Studies differ in terms of the mental health of different groups of gender diverse people, especially non-binary people, trans women, and trans men. Further, the role of intersectionality inflects mental health outcomes, although further work is needed to clearly detail this. Physical management of gender dysphoria through the use of hormones and/or surgeries for appropriate people is of great assistance in alleviating mental distress. As always, discrimination and minority stress  adversely affect mental health outcomes and point to the need for further society-level work to address prejudice, both explicit and implicit, against gender diverse people.

Background: The number of minors contacting specialized gender identity services has been on the increase throughout 2010’s, and research on child and adolescent gender dysphoria / transgender identity is also expanding. Mental health is an important aspect of this research.

Methods: This review focuses on mental health aspects of child and adolescent gender dysphoria and transgender identity in research published since spring 2019.  A systematic search was carried out in Medline and Psychinfo databases. References used in selected publications and Google Scholar database were further searched to enrich material on emerging or controversial topics.

Results and Conclusions: It was known that minors presenting in gender identity services commonly display co-occurring mental disorders, particularly internalizing disorders. A few more studies presenting baseline characteristics with fairly similar findings have emerged. Follow-up studies that would have potential to demonstrate the impact of gender affirming treatments on mental health are only a few, have small numbers of participants, short follow-up times and other methodological limitations, and a limited array of mental health outcomes, and their outcomes as to mental health are mixed. Studies exploring mental health issues among transgender identifying adolescents in the population are cross-sectional and often based on selected populations, and thus they have limited potential for shedding light on any causal relationships. However they suggest firstly, that transgender identifying adolescents present with mental health problems more commonly than their cisgender peers, and secondly, that problems in relationships with parents, lack of parental support and peer problems such as bullying are important correlates of mental health problems in transgender identifying adolescents, as among children and adolescents at large. Transgender identifying adolescents in community samples appear to report both internalizing and externalizing problems more commonly than cisgender youth. A large bulk of literature comprises reviews and recommendations for various health care professionals, without presenting new research findings. Methodological limitations in the whole research field are considerable and should be kept in mind when making any causal assumptions.

Background: As the number of people applying for gender affirming care keeps increasing at all European gender clinics, it is obvious that the demand for gender affirming care also continues to grow. Unfortunately, gender affirming endocrine care is still relatively scarce, as not all endocrinologists get involved. This may be due to limited data on gender affirming endocrine care.

Aim(s): To identify important recent publications on endocrine aspects of transgender health.

Methods: A thorough PubMed, Embase and Google Scholar literature search was conducted. Articles on gender affirming endocrine care, published between January 1 2018 and April 1 2021 were analysed.

Main Outcome Measures: Publications included in the presentation were selected based on their novelty, importance and potential impact on gender affirming endocrine care.

Results: This review will highlight the main findings from key endocrine publications since the last EPATH conference.

Introduction: The overview of the research since the last EPATH Conference in Rome will be systematic narrative review. Using Scopus, I identified six substantive themes in the research being produced and I include another which are key studies informing health and wellbeing in trans populations.

Methods: Scopus data base was used to identify articles from Social and Political science disciplines and its contribution to trans health and wellbeing. Inclusion criteria was articles from Sept 2019-May 2021, European, written in English, peer reviewed, and understood by the speaker to be research contributing to the understanding of the social and political aspects of health and wellbeing for trans, non-binary and intersex people. 137 papers were found, with the keywords trans, transgender, non-binary, intersex. Each abstract was assessed by the speaker to be relevant to the social and political sciences. All commentaries, opinion pieces and letters to editors were removed from the review.

Results: 74 papers were identified following reading of articles. This culminated in 6 themes: Anti-trans movements, Young trans and non-binary people and schooling, Fertility, fertility preservation technologies and experiences of pregnancy and parenthood, Sex and sexuality, Ageing and trans and non-binary populations and Sport and exercising. A final theme is included: Key studies informing health and wellbeing. This review highlights that trans, non-binary and intersex people continue to experience barriers to equitable health and wellbeing services.

Background: The majority of transgender and gender diverse persons seeking medical care are of reproductive age. Gender affirming hormonal treatment and surgery adversely affect the future reproductive potential. According to international guidelines, fertility preservation should be discussed before any gender treatment. However the reproductive options and needs of transgender and gender diverse persons may ask for a specific approach. Evidence on gender specific reproductive health, fertility preservation options and outcome is scarce and a bit diffused.  All the more important to provide an overview of the most relevant insights in this field.

Methods: PubMed, Embase and Google Scholar were searched to screen the literature. Mostly recent papers from 2019 onward on fertility, childwish and fertility preservation in gender population were included.

Results and Conclusions: This presentation will aim to cover the main findings from key publications on reproductive health in transgender people which have been published over the last years.

Background: Transgender or gender diverse individuals may experience incongruence between their gender identity and the qualities of their voice and communication. Voice services for gender diverse people experiencing voice and communication difficulties is a growing specialty within speech-language pathology and laryngology. In the past, there was a considerable imbalance of voice research focusing on people assigned male at birth. However, a gradually increasing number of studies have been published regarding voice and communication in a gender diverse population. The purpose of this presentation is to provide an overview of the current literature regarding voice and communication in a gender diverse population from the previous EPATH conference until 2021.

Methods: Three electronic databases were searched for literature between 2019 and July 1^st, 2021: MEDLINE (PubMed), Embase and Web of Science. Two concepts (gender diverse and communication) were combined. After removing duplicates in Endnote, title and abstract screening was performed. Further data-extraction of the full-texts was completed and summarized in 8 themes: “theoretical framework”, “voice function”, “questionnaires and tools”, “laryngeal surgery”, “voice training”, “voice changes under gender affirming hormonal treatment”, “gender perception”, and “training, attitudes, knowledge of speech language pathologists”. The presentation focuses on the first 5 themes.

Results and Conclusions: In total, 2018 records were identified through the database search. After duplicate removal, title, abstract and full-text screening, 83 records were retained.

A new transdisciplinary theoretical model for vocology is proposed by Azul & Hancock, changing perspectives in the field. This model draws attention to the interactive process through which voice is constructed during communication, between material forces, speaker, listener, environment, interventions and socio-cultural context.

Recent research on voice function focuses on a more diverse population and shows that the prevalence of voice-gender incongruence is high in transgender, nonbinary and gender-nonconforming people. However, gender diverse clients, especially transmasculine people, experience a variety of barriers to access voice services. There is a need for questionnaires and tools investigating voice function, needs and experiences in a broader gender diverse population. The VENI (Voice-related Experiences of Nonbinary Individuals), developed in 2021, is the first assessment tool that measures self-perception of voice in nonbinary individuals. The Trans Women Voice Questionnaire (TWVQ) was renamed in July 2020 and has been translated and adapted in several languages.

For laryngeal surgery, new evidence for pitch lowering surgical techniques (thyroplasty type III and vocal fold injection augmentation) is found. For pitch raising surgery most recent studies focused on the outcome of glottoplasty. Computational models show that the optimal length of fixation is a compromise between pitch elevation and reduction in output acoustic power.

Evidence for voice training in transgender people is growing. Recent studies show a positive outcome for the use of biofeedback in speech feminization training. For speech masculinization training, group therapy and manual laryngeal therapy in a small group of transmasculine people was effective. In further research, there is a need for effectiveness studies using Randomized Control Trial designs with larger sample sizes and long-term follow-up to assess which techniques are most effective and to determine outcome predictors.

Gender surgery summarizes a variety of remodeling operations as feminizing or masculinizing genital reassignment, chest modification and facial surgery, which are the most common procedures, or modifications of the hands, up to now a less often used procedure. Concerning those different topics several methods have been described without having established standards up to now. This is an ambitious aim of a German guideline just in progress. Besides presenting the diversity of the surgical methods the guideline will point out indications or more important contraindications for surgery, inform about pre- and postoperative requirements and deal with trouble shooting.
The lecture given will present some new trends and aspects concerning genital reassignment in the one and other direction including new literature and personal experience. The question about risk of prostate cancer in transgender women comes up. Full facial feminization, what is better, an all in one procedure or a 2-stage procedure? The current literature about modification of the hands will be presented.
Perfect surgery without severe complications is what the surgeon aims at. But does this also reflect the patient’s point of view. Measurement of quality of life outcomes is of special interest. Another important aspect for patients‘ wellbeing are their psychosocial resources. Recently a new score concerning this topic has been developed and validated in Germany.

Background: Review of studies on the ethical issues around the clinical management of gender diverse and transgender children and adolescents.

Methods: key word search using Ingenta Connect, Pro/Quest Central UK/Ireland, PubMed Central, Springer Online Journals, Wiley Online Library Full Collection 2019 and Wiley Online Library All Journals, Springer Links Journals. Key words: ethics, puberty suppression; ethics transgender children

Results and Conclusions: The number of publications on the care of gender diverse young people has increased significantly in the last two years. Most of the papers do not provide an ethical analysis; they are clinical papers which present an ethical dilemma; this seems to indicate a need, on the part of the authors, at times explicitly acknowledged, to engage more directly with ethicists in the exploration of the ethical issues emerging in the care and treatment of gender diverse young people. Five thematic areas of concern emerge from the review of the literature:

1. Ethical issues in the provision of long-term GnRHa to non-binary adolescents;
2. Ethical issues in the provision of genital surgery to minors;
3. Ethical issues around consent and the role of the court (Bell v Tavistock; AB v CD);
4. Ethical issues around family involvement;
5. Ethics of puberty delay.

The recent legal ruling in England (December 2020 and March 2021) appear shaped by a number of long standing ethical concerns around the nature of gender treatment, the ability of adolescents to be competent decision-makers, and the long term potential risks of early medical intervention.