Jaimie F. Veale

The Case for the World Health Organization’s Commission on Social Determinants of Health to Address Gender Identity

We analyzed the case of the World Health Organizations Commission on Social Determinants of Health, which did not address gender identity in their final report. We argue that gender identity is increasingly being recognized as an important social determinant of health (SDH) that results in health inequities. We identify right to health mechanisms, such as established human rights instruments, as suitable policy tools for addressing gender identity as an SDH to improve health equity. We urge the World Health Organization to add gender identity as an SDH in its conceptual framework for action on the SDHs and to develop and implement specific recommendations for addressing gender identity as an SDH.

Non-binary youth: Access to gender-affirming primary health care

ABSTRACT Background: Transgender (trans) youth who identify outside the gender binary are a growing subpopulation. In this article, we document differences in access to gender-affirming health care between binary and non-binary identified trans youth and explore ways of meeting the health needs of non-binary youth within primary care settings. Methods: The Canadian Trans Youth Health Survey is a national online survey of trans youth, 14–25 years, conducted in 2013–2014. Among the 839 participants who responded to gender identity items in the survey, 41% identified as non-binary. We compared demographic, health outcome, and health care access responses between non-binary and binary (trans girls/women and trans boys/men) youth. Results: Non-binary and binary youth were similar in most demographics, including age, geographic distribution, and ethnocultural backgrounds, however a larger proportion (82%) of non-binary youth were assigned female at birth. Older non-binary youth (aged 19–25) were significantly more likely to forego needed healthcare than older binary youth; no significant differences were found between younger (14–18) non-binary and binary youth in foregoing healthcare. Overall, non-binary youth (13%) were significantly less likely than binary youth (52%) to access hormone therapy, but they were more likely than binary youth to report experiencing barriers to accessing hormone therapy when needed. Conclusions: Non-binary trans youth in Canada report challenges in accessing needed gender-affirming healthcare. Primary care providers are well-situated to integrate a broad range of gender-affirming care services into practice in order to address the unique needs of non-binary youth. Future research is warranted to explore experiences of non-binary youth related to barriers to care and to explore how services can be designed and delivered to better meet the needs of non-binary youth seeking gender-affirming primary care.

Prevalence of pregnancy involvement among Canadian transgender youth and its relation to mental health, sexual health, and gender identity

ABSTRACT While little research has been conducted into the reproductive experiences of transgender people, available evidence suggests that like cisgender people, most transgender people endorse a desire for these experiences. This study explores the pregnancy experiences and related health factors among transgender and gender diverse 14 to 25 year olds using a national Canadian sample (N = 923). Results indicated that 26 (5%) transgender youth reported a pregnancy experience in the past and the prevalence among 14- to 18-year-olds was comparable to population-based estimates using the same question in the British Columbia Adolescent Health Survey. Transgender youth with a history of pregnancy involvement reported a diverse range of gender identities, and this group did not differ from the remainder of the sample on general mental health, social supports, and living in felt gender. This group did report over six times greater likelihood of having been diagnosed with a sexually transmitted infection by a doctor (19%), but they did not differ in reported contraception use during last sexual intercourse. These findings suggest that pregnancy involvement is an issue that should not be overlooked by health professionals working with transgender youth and that this group has particular sexual health needs.

Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors

PURPOSE Research has documented high rates of disordered eating for lesbian, gay, and bisexual youth, but prevalence and patterns of disordered eating among transgender youth remain unexplored. This is despite unique challenges faced by this group, including gender-related body image and the use of hormones. We explore the relationship between disordered eating and risk and protective factors for transgender youth. METHODS An online survey of 923 transgender youth (aged 14-25) across Canada was conducted, primarily using measures from existing youth health surveys. Analyses were stratified by gender identity and included logistic regressions with probability profiles to illustrate combinations of risk and protective factors for eating disordered behaviors. RESULTS Enacted stigma (the higher rates of harassment and discrimination sexual minority youth experience) was linked to higher odds of reported past year binge eating and fasting or vomiting to lose weight, while protective factors, including family connectedness, school connectedness, caring friends, and social support, were linked to lower odds of past year disordered eating. Youth with the highest levels of enacted stigma and no protective factors had high probabilities of past year eating disordered behaviors. DISCUSSION Our study found high prevalence of disorders. Risk for these behaviors was linked to stigma and violence exposure, but offset by social supports. Health professionals should assess transgender youth for disordered eating behaviors and supportive resources.

Toward Global Comparability of Sexual Orientation Data in Official Statistics: A Conceptual Framework of Sexual Orientation for Health Data Collection in New Zealand’s Official Statistics System

Objective. Effectively addressing health disparities experienced by sexual minority populations requires high-quality official data on sexual orientation. We developed a conceptual framework of sexual orientation to improve the quality of sexual orientation data in New Zealands Official Statistics System. Methods. We reviewed conceptual and methodological literature, culminating in a draft framework. To improve the framework, we held focus groups and key-informant interviews with sexual minority stakeholders and producers and consumers of official statistics. An advisory board of experts provided additional guidance. Results. The framework proposes working definitions of the sexual orientation topic and measurement concepts, describes dimensions of the measurement concepts, discusses variables framing the measurement concepts, and outlines conceptual grey areas. Conclusion. The framework proposes standard definitions and concepts for the collection of official sexual orientation data in New Zealand. It presents a model for producers of official statistics in other countries, who wish to improve the quality of health data on their citizens.

Evidence against a typology: a taxometric analysis of the sexuality of male-to-female transsexuals.

Previous theories and research have suggested there are two distinct types of male-to-female (MF) transsexuals and these types can be distinguished by their sexuality. Using the scales Attraction to Femininity in Males, Core Autogynephilia, Autogynephilic Interpersonal Fanasy, and Attraction to Transgender Fiction as indicator variables, taxometric analysis was applied to an online-recruited sample of 308 MF transsexuals to investigate whether such a distinction is justified. In accordance with previous research findings, MF transsexuals categorized as “nonandrophilic” scored significantly higher on Core Autogynephilia than did those categorized as “androphilic”; they also scored significantly higher on Attraction to Femininity in Males and Attraction to Transgender Fiction. Results of one of the taxometric procedures, L-Mode, gave slightly more support for a dimensional, rather than taxonic (two-type), latent structure. Results of the two other taxometric procedures, MAMBAC and MAXCOV, showed greater support for a dimensional latent structure. Although these results require replication with a more representative sample, they show little support for a taxonomy, which contradicts previous theory that has suggested MF transsexuals’ sexuality is typological.

Enacted Stigma, Mental Health, and Protective Factors Among Transgender Youth in Canada

Abstract Purpose: We aimed to assess the Minority Stress Model which proposes that the stress of experiencing stigma leads to adverse mental health outcomes, but social supports (e.g., school and family connectedness) will reduce this negative effect. Methods: We measured stigma-related experiences, social supports, and mental health (self-injury, suicide, depression, and anxiety) among a sample of 923 Canadian transgender 14- to 25-year-old adolescents and young adults using a bilingual online survey. Logistic regression models were conducted to analyze the relationship between these risk and protective factors and dichotomous mental health outcomes among two separate age groups, 14- to 18-year-old and 19- to 25-year-old participants. Results: Experiences of discrimination, harassment, and violence (enacted stigma) were positively related to mental health problems and social support was negatively associated with mental health problems in all models among both age groups. Among 14–18 year olds, we examined school connectedness, family connectedness, and perception of friends caring separately, and family connectedness was always the strongest protective predictor in multivariate models. In all the mental health outcomes we examined, transgender youth reporting low levels of enacted stigma experiences and high levels of protective factors tended to report favorable mental health outcomes. Conversely, the majority of participants reporting high levels of enacted stigma and low levels of protective factors reported adverse mental health outcomes. Conclusion: While these findings are limited by nonprobability sampling procedures and potential additional unmeasured risk and protective factors, the results provide positive evidence for the Minority Stress Model in this population and affirm the need for policies and programs to support schools and families to support transgender youth.

The scales and sample were adequate for the purpose: reply to Lawrence's (2014) critique of my taxometric analysis of the sexuality of transsexual women.

Blanchard (1989b) proposed that there are two categorically distinct types of transsexual women (male-to-female transsexuals) and this typology isbasedonone of these types havingsexualattractiontooneselfasawoman.Helabeledthis typeofsexual attraction autogynephilia. Blanchard proposed that those who do not experience autogynephilia are sexually attracted only to men (androphilic) and those who experience autogynephilia are sexuallyattracted towomenonly,bothmenandwomen,andneither menorwomen(non-androphilic). Iconductedataxometricanalysis (Ruscio,Haslam,&Ruscio,2006) toassesswhether thesexuality of transsexual women was more consistent with a dimensionalortwotaxa(category)structure(Veale,2014).Inopposition to Blanchard’s theory, the study’s findings were more consistent with a dimensional structure. Lawrence(2014)critiquedmystudy,suggestingthatthescalesI used were not appropriate for the task and that the sample I used lacked sufficient numbers of androphilic transsexual women. In this Letter, I respond to Lawrence’s criticisms.

Transgender youth are strong: Resilience among gender expansive youth worldwide

We are thrilled to present a special collection of empirical papers, critical commentaries/reviews, and a book review in the International Journal of Transgenderism. We called for cutting-edge research that explored the experiences of transgender young populations as it relates to health, well-being, and/or school achievement and experiences. We were particularly interested in scholarship focused on opportunities for resilience and reducing stigma among the trans youth population. We selected works that focused on resiliency among transgender and gender expansive young people. This special issue is published by the International Journal of Transgenderism with support from the Public Discourse Project at the University of Connecticut in Storrs, Connecticut, USA. Included in this special issue are 10 exciting contributions that advance the scholarship regarding the health and well-being of gender expansive young people. The impetus for this special issue was the plethora of recent troubling legislation that have limited and removed sundry rights of transgender individuals. As a result of divisive rhetoric, transgender youth often face particular challenges related to acceptance by their families, at school, and in the larger community. Our own previous scholarship (Veale et al., 2016; Watson, Veale, & Saewyc, 2017) identified disparities among transgender youth, yet we also identified particular contexts for resilience that mitigated negative mental health and disordered eating. By way of this special issue, we sought to collect contemporary scholarship that extended this emerging body of literature. Among 10 contributions, 6 are empirical papers. The collection of these papers approached resiliency from multiple lenses – from school-based clubs as tools for engagement in advocacy, to proactivity and self-care as strategies to mitigate struggles. These empirical articles focused on diverse contexts, including school, the media, and religious contexts. We begin with the U.S. context, where an emerging body of research focused on the lived experiences of transgender young people (e.g., Katz-Wise et al., 2017; Reisner et al., 2015). The first paper included in this collection analyzed responses from 295 gay-straight alliance (GSA) members from across 33 U.S. high schools and found significant variations in gender diversity discussions across GSAs and among youth within each GSA (Poteat et al., 2018). Poteat and colleagues found that higher levels of advocacy within GSAs was associated with having more transgender friends and perceiving respectful climates in GSAs. This paper makes a valuable contribution given emerging evidence finds increasing school-based disparities for transgender youth across the U.S. (Kosciw, Greytak, Giga, Villenas, & Danischewski, 2016). Moving from the institution of school to that of families, Aramburu Alegr ıa (2018) explored the characteristics of supportive families, in particularly related to the well-being of transgender youth. As part of the first wave of a longitudinal study, Aramburu Alegr ıa interviewed 14 parents of 12 transgender youth aged 6 to 17; she found that among socially transitioned youth, parents tended to grant independence and facilitated selective disclosure of trans identities to best support their trans youth. Established supportive networks, such as counselors, were leveraged to provide camaraderie and promote resilience among the youth in the sample. While Aramburu Alegr ıa consistently heard about struggles parents endured—notably dealing with uncertainty surrounding the child’s future and safety—she concluded that when parents were able to work with their child to socially transition, she in turn found the youth to be happier and more engaged. These findings corroborate previous scholarship that has found parents and family to be essential in the well-being of transgender youth as they transition through adolescence (Klein & Golub, 2016; Watson et al., 2017). Of course, many transgender young people do not have access to supports in schools or from family members—a significant number of homeless young

Primary care access and foregone care: a survey of transgender adolescents and young adults

Abstract Objective To examine the issues of primary care access and foregone health care among transgender adolescents and young adults. Methods This cross-sectional analysis of data from the Canadian Trans Youth Health Survey was conducted online during 2013–2014. Participants included 923 youth aged 14–25 (323 adolescents aged 14–18 and 600 young adults aged 19–25). Main outcome measures were self-reported general and mental health status, comfort discussing transgender identity and health care needs with general practitioners, and types of and reasons for self-identified foregone health care. Results Most youth reported poor/fair general and mental health status. Comfort with a family doctor was positively correlated with both general health (r(528) = 21, P < 0.001) and mental health (r(450) = 26, P < 0.001) status, as was having a doctor who was aware of one’s transgender status. 47.2% (n = 219) of young adults reported foregoing needed health care. Among adolescents, levels of comfort with family doctor were negatively correlated with foregone mental health care in the previous 12 months (F3,166 = 3.829, P = 0.011), but not correlated with foregone physical health care (F3,165 = 0.506, P = 0.679). Reasons for missing needed care spanned the dimensions of health care access, ranging from cost barriers to previous negative experiences with health care providers, and concerns that a doctor would be uneducated about transgender people. Conclusion General practitioners can play a key role in improving the health of transgender youth by demonstrating understanding of the health care needs of transgender youth and competence in gender-affirming care, and by ensuring that their practices are accessible to all transgender youth in need of care.