Gender Incongruence of Childhood: Clinical Utility and Stakeholder Agreement with the World Health Organization's Proposed ICD-11 Criteria.

The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.

Gender Incongruence of Adolescence and Adulthood: Acceptability and Clinical Utility of the World Health Organization's Proposed ICD-11 Criteria.

The World Health Organization (WHO) is currently updating the tenth version of their diagnostic tool, the International Classification of Diseases (ICD, WHO, 1992). Changes have been proposed for the diagnosis of Transsexualism (ICD-10) with regard to terminology, placement and content. The aim of this study was to gather the opinions of transgender individuals (and their relatives/partners) and clinicians in the Netherlands, Flanders (Belgium) and the United Kingdom regarding the proposed changes and the clinical applicability and utility of the ICD-11 criteria of 'Gender Incongruence of Adolescence and Adulthood' (GIAA). A total of 628 participants were included in the study: 284 from the Netherlands (45.2%), 8 from Flanders (Belgium) (1.3%), and 336 (53.5%) from the UK. Most participants were transgender people (or their partners/relatives) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both healthcare providers and (partners/relatives of) transgender people. Participants completed an online survey developed for this study. Most participants were in favor of the proposed diagnostic term of 'Gender Incongruence' and thought that this was an improvement on the ICD-10 diagnostic term of 'Transsexualism'. Placement in a separate chapter dealing with Sexual- and Gender-related Health or as a Z-code was preferred by many and only a small number of participants stated that this diagnosis should be excluded from the ICD-11. In the UK, most transgender participants thought there should be a diagnosis related to being trans. However, if it were to be removed from the chapter on "psychiatric disorders", many transgender respondents indicated that they would prefer it to be removed from the ICD in its entirety. There were no large differences between the responses of the transgender participants (or their partners and relatives) and HCPs. HCPs were generally positive about the GIAA diagnosis; most thought the diagnosis was clearly defined and easy to use in their practice or work. The duration of gender incongruence (several months) was seen by many as too short and required a clearer definition. If the new diagnostic term of GIAA is retained, it should not be stigmatizing to individuals. Moving this diagnosis away from the mental and behavioral chapter was generally supported. Access to healthcare was one area where retaining a diagnosis seemed to be of benefit.

People with gender dysphoria who self-prescribe cross-sex hormones: prevalence, sources, and side effects knowledge.

INTRODUCTION: There is a scarcity of research into the use of non-physician-sourced cross-sex hormones in the transgender population. However, when medication is not prescribed by health professionals, users' knowledge of such medication may be adversely affected. AIMS: This study aims to define the prevalence of Internet-sourced sex hormone use in a population attending for initial assessment at a gender identity clinic, to compare the prevalence between gender-dysphoric men and women, and to compare knowledge of cross-sex hormone side effects between users who source cross-sex hormones from medical doctors and those who source them elsewhere. METHODS: In the first part of the study, a cross-sectional design is used to measure the overall prevalence of sex hormone use among individuals referred to a gender clinic. The second part is a questionnaire survey aiming at measuring sex hormone knowledge among individuals referred to this clinic. MAIN OUTCOME MEASURES: Main outcome measures were (i) categorical data on the prevalence and source of cross-sex hormone use and (ii) knowledge of sex hormone side effects in a population referred to a gender clinic. RESULTS: Cross-sex hormone use was present in 23% of gender clinic referrals, of whom 70% sourced the hormones via the Internet. Trans men using testosterone had a sex hormone usage prevalence of 6%; one-third of users sourced it from the Internet. Trans women had a sex hormone usage prevalence of 32%; approximately 70% of users sourced hormones from the Internet. Cross-sex hormone users who sourced their hormones from physicians were more aware of side effects than those who used other sources to access hormones. CONCLUSION: One in four trans women self-prescribe cross-sex hormones before attending gender clinics, most commonly via the Internet. This practice is currently rare among trans men. Self-prescribing without medical advice leaves individuals without the knowledge required to minimize health risks.

Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls.

INTRODUCTION: There is a paucity of research in the area of social support and psychological well-being among people with gender dysphoria. AIMS: The present study aimed to investigate levels of social support among individuals with gender dysphoria compared with a matched control group. It also aimed to examine the relationship between social support and psychological well-being. METHODS: Participants were 103 individuals diagnosed with gender dysphoria (according to ICD-10 criteria) attending a national gender identity clinic and an age- and gender-matched nonclinical control group recruited via social networking websites. MAIN OUTCOME MEASURES: All participants completed measures of social support (Multidimensional Scale of Perceived Social Support, MSPSS), psychopathology (Symptom Checklist 90 Revised, SCL), quality of life (Short Form 36 version 2, SF), and life satisfaction (Personal Wellbeing Index, PWI). RESULTS: Trans women reported significantly lower MSPSS total and MSPSS family scores compared with control women, although these differences in levels of social support were no longer significant when SCL depression was controlled for. No significant differences were found between trans men and any other group. MSPSS scores did not significantly predict SCL subscales but did predict both SF subscales and PWI total scores. CONCLUSIONS: Trans women perceived themselves to be lacking social support. Given that social support is beneficial to quality of life and life satisfaction in those with gender dysphoria, this is of great concern. Though these findings have been derived from correlational results, extended research may highlight the value of clinicians helping trans women to seek out and maintain social support. Additionally, efforts could be made to educate and challenge attitudes of nontrans people towards those with gender dysphoria.

A prospective study of cognitive tests to predict performance on a standardised road test in people with dementia.

OBJECTIVE: Previous work by Lincoln and colleagues produced a cognitive test battery for predicting safety to drive in people with dementia. The aim was to check the accuracy of this battery and assess whether it could be improved by shortening it, including additional cognitive tests, and a measure of previous driving. METHODS: Participants with dementia, who were driving, were recruited. They were assessed on cognitive tests including measures of concentration, executive function, visuospatial perception, verbal recognition memory, and speed of information processing. Patients were then assessed on the Nottingham Neurological Driving Assessment (NNDA) by an approved driving instructor (ADI), blind to cognitive test results. RESULTS: Seventy-five patients were recruited and completed the cognitive tests. Of these, 65 were assessed on the road. These participants were aged 59-88 (mean = 75.2, SD = 6.8) and 49 were men. Time driving varied from 19 to 73 years (mean = 52.5, SD = 10.0). Thirteen participants were unsafe and 52 safe to drive. Using a cut-off of > 0 to indicate safety to drive, the original predictive equations correctly classified 48 (76.2%) of 63 participants with complete data. Logistic regression including additional tests reduced misclassifications. CONCLUSIONS: A lower proportion of participants were found to be unsafe on the road than in previous studies. Nevertheless, the previously identified equation predicted safety to drive in most patients. Including additional tests reduced the misclassification rate but requires independent validation. We suggest that the cognitive test battery might be used in clinical practice to identify patients with dementia who would benefit from on-road assessment.

Treating young people with eating disorders: transition from child mental health to specialist adult eating disorder services.

BACKGROUND: The transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) of young people with eating disorders may pose a number of difficulties, including an inconsistent referral process and age boundaries. METHODS: We compared young adults referred to a specialist Adult Eating Disorders Service (AEDS) who had previous involvement with CAMHS for the treatment of their eating disorder with those who did not. Information regarding the socio-demographic characteristics and eating disorders symptomatology of patients assessed by an AEDS over a 4-year period was collected. RESULTS: Patients who had previous involvement with CAMHS (particularly the ones treated as in-patients) presented with a lower self-esteem and more maturity fears (MF) than those without previous involvement. CONCLUSIONS: This study discusses the implication of these results in transitional arrangements between CAMHS and Adult services. It also highlights the need for heightened awareness of particular issues of self-esteem and maturation in these patients moving between services.