Challenging and understanding gendered narratives: the development and validation of the transnormativity measure (TM).

Background: Transnormativity refers to the accountability structure that regulates the acceptable gender presentations, narratives, and ways of being of trans and nonbinary (TNB) individuals.Aims: The present research extends prior qualitative research on transnormativity to develop and validate the Transnormativity Measure (TM). Methods: The initial developed pool of potential items was presented to a focus groups and three content experts for review. In Study 1 (N = 497), the 69 initial items of the TM hypothesized to underly a six-factor structure were analyzed using Exploratory Factor Analysis (EFA) and construct and discriminant validity were assessed. In Study 2 (N = 540), an independent sample of TNB participants' TM responses were subjected to Confirmatory Factor Analysis (CFA), invariance testing, and construct and predictive validity. Finally, in Study 3 (N = 107), an Interclass Correlation Coefficients 2-way mixed-effects model of the TM was assessed.Results: EFAs conducted in Study 1 revealed a two-factor structure as the best fit with 50 items removed. Conceptually there was considerable overlap in the items comprising the two factors and it was decided that one general factor should be utilized. Study 1 also provided preliminary construct and discriminant validity due to expected relations between the TM and existing measures of heteronormativity and internalized transphobia. In Study 2 findings from correlational tests of the remaining items revealed that four items were highly correlated and were removed. Subsequent CFA indicated that the one factor model fit the data well. Configural invariance was supported however metric noninvariance was found. Additionally, Study 2 results supported construct and predictive validity through correlations between the TM and measures of TNB community belonginess and mental health outcomes. Finally, Study 3 provided support for test-retest reliability. Discussion: Across three studies, the TM was found to be a valid measure of transnormativity.

Transgender and nonbinary patients' psychotherapy goals: A secondary analysis from a randomized controlled trial.

OBJECTIVE: Goal setting is an important factor that contributes to positive outcomes in psychotherapy, yet research has not focused on this particular aspect of process and outcome of psychotherapy for transgender and nonbinary (TNB) patients. METHODS: The present study used secondary data analysis from a pilot randomized controlled trial focused on trans-affirmative therapy for TNB patients (N = 19). The aims of the present study were twofold: 1) gain an in-depth understanding of goals prior to the course of psychotherapy for TNB patients and 2) determine the outcome of goal setting after a 12-session course of psychotherapy with TNB patients. Content analysis and descriptive statistics were used to analyze the data. RESULTS: Results indicated that the majority (70%) of goals were met at termination. The results also indicated that the majority of goals (73%) were not related to gender. The content analysis revealed that there were five overarching themes regarding the types of goals described by TNB patients: 1) managing mental health symptoms, stress, and distress; 2) developing skills to improve well-being; 3) working on relationships; 4) exploring and understanding of trans identity (gender identity); and 5) orienting towards positive growth and development. Patients' mean scores indicated that goals focused on developing skills to improve well-being were rated the highest regarding change over the course of 12 sessions of psychotherapy. CONCLUSIONS: This study illuminates the importance of assessing TNB patients' goals and understanding which goals resulted in the highest amount of self-reported change over 12 sessions of psychotherapy.

"We don't have a template to follow": Sexual identity development and its facilitative factors among sexual minority men in the context of China.

Extant research on sexual identity development among sexual minority individuals has been predominantly conducted in Western contexts and focused on factors that hinder identity development processes. Using thematic analysis, this qualitative study sought to explore the experiences of sexual identity development among Chinese sexual minority men as well as the facilitative factors in China that positively influence this developmental process. The sample comprised 24 participants who self-identified as Chinese sexual minority men. The analysis yielded five overarching themes: awareness of one's attraction and corresponding reactions, identity exploration, moving toward identity acceptance and commitment, acceptance and support from others, and environmental support. The first three themes described the processes of sexual identity development among Chinese sexual minority men, whereas the latter two themes centered on the related facilitative factors in the context of China. The results highlight the importance of understanding the identity development process within Chinese minority men's unique sociocultural contexts. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people.

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

Latinx trans immigrants' survival of torture in U.S. detention: A qualitative investigation of the psychological impact of abuse and mistreatment.

BACKGROUND: A trans person is murdered every 3 days in the world, with the majority of these murders occurring in Latin America. This violence is a motivating factor for Latinx trans immigrants to immigrate to the United States. Regardless of whether individuals may be able to remain in the U.S., trans immigrants and asylum seekers are often held in detention facilities until immigration courts decide their cases. Although there are several standards of care and guidelines produced for trans and nonbinary (TNB) people who are held in detention, various reports have indicated that Immigration and Customs Enforcement (ICE) has not or inappropriately implemented these guidelines, thereby incurring and increasing risk of harm upon TNB immigrants. AIMS: This qualitative study used thematic analysis to provide an understanding of the psychological impact that the systemic power of US detention proceedings had on the lives of Latinx, trans immigrants. METHOD: The semi-structured interview protocol and implementation of this study was developed in collaboration with two national Latinx, LGBTQ immigrant advocacy organizations. The sample included 30 trans participants, between the ages of 18 and 52 (M = 23) who immigrated from El Salvador (40%), Guatemala (23%), México (17%), Honduras (17%), and Peru (3%). RESULTS: Participants reported being subject to debilitating and torturous conditions in "La Hielera", torture and abusive treatment by detention authorities, being denied access to basic human needs and medical care, and held in solitary confinement as punishment. This dehumanization, abuse, and transphobia in detention incurred psychological sequelae on participants including trauma, anxiety and depression, suicidal ideation, and a preference to self-deport. DISCUSSION: Implications include calls to abolish immigration detention, recommendations for mental health providers, and an overall restructuring of policies and services for humane asylum seeking processes for trans, Latinx immigrants.

The relationship between realization of transgender identity and transition processes with nonsuicidal self-injury in transgender populations.

We hypothesized that transgender and nonbinary (TNB) individuals who reported a longer period of time from realizing they were TNB to beginning their transition will have a longer history of nonsuicidal self-injury (NSSI) and that participants who report higher levels of body investment, fewer years from realization of TNB identity to transition, and more years since NSSI will report lower levels of current anxiety, stress, and depression. We conducted a secondary data analysis of a dataset collected online, which included 217 participants. We conducted multiple regressions to explore the hypotheses. Results revealed that TNB people who had a longer time between realizing their gender identity and beginning a transition had a longer history of NSSI. Exploratory analyses were also conducted to help understand the relationship between NSSI, transition, and body investment on mental health outcomes. Providers are cautioned that the presence of NSSI should not necessarily be a contraindication to transition.

The development of an observational coding scheme to assess transgender and nonbinary clients' reported minority stress experiences.

Trans and nonbinary individuals experience high rates of identity-based stigma and stress (minority stress) in U.S. society. Despite research empirically linking minority stress with adverse mental health outcomes, the extent to which minority stress experiences are discussed in psychotherapy and how therapists respond is unknown. The primary aim of the present study was to develop and test an observational coding scheme, the Minority Stress Experiences and Interactions (MSEI) scheme. With this scheme, observational data from psychotherapy sessions with 19 transgender and nonbinary adult psychotherapy client participants were coded to provide pilot data for the initial development of the MSEI coding scheme. A total of 19 clients' entire 50-min psychotherapy sessions were coded over 3 phases of psychotherapy: beginning (Session 1), middle (Session 2), and end (Session 10/11). Results indicate that the MSEI scheme was reliable for most codes. Codes revealed that all (N = 19; 100%) clients in the study reported at least 1 minority stress event (MSE) over the course of the 3 sessions, with the mean number of MSEs being 7 per client. The most frequent proximal stressor reported by clients was related to internalized stigma and the most frequent distal stressor reported by clients was prejudice. A total of 2 clients' clinical exchanges with their therapists centered on MSEs are highlighted to demonstrate the nuance of how MSEs are discussed in session, specifically regarding multiple minority identities. Implications for the current study include the need for therapist training regarding minority stress interventions and attention to power and oppression within sessions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Longitudinal effects of psychotherapy with transgender and nonbinary clients: A randomized controlled pilot trial.

Minority stress has been determined to contribute to some mental health concerns for transgender, nonbinary, and gender nonconforming individuals, yet little is known regarding interventions to decrease the effects of minority stress. The purpose of this pilot study was to assess the feasibility and relative effectiveness of two interventions developed for work with transgender clients. Transgender individuals (N = 20) were recruited to participate in a randomized controlled trial comparing two psychotherapy interventions for transgender adults seeking psychotherapy for a variety of concerns: (a) transgender affirmative psychotherapy (TA) and (b) Building Awareness of Minority Stressors + Transgender Affirmative psychotherapy. Gender-related stress and resilience were assessed before, immediately after, and 6 months following the intervention; psychological distress and working alliance were assessed at these three time points as well as weekly during the intervention. Feasibility and acceptability of the study and psychotherapy interventions were supported. Exploratory analyses indicate improvement in both groups based on general outcome measures; targeted outcome measures indicate a trend of improvement for internalized stigma and nonaffirmation experiences. Results from this study support further evaluation of both treatment arms in a larger randomized controlled trial. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Conceptualizing relationships among transgender and gender diverse youth and their caregivers.

Family support and acceptance are protective for transgender and gender diverse (TGD) youths' mental health and identity development. Although some studies have examined the role of supportive family relationships for TGD youth, prior research has not fully explored how TGD youth and their caregivers understand or characterize these relationships within the family system. In this qualitative study, we explored perspectives of TGD youth and their caregivers regarding youth-caregiver and caregiver-caregiver relationships within the family system. We recruited a community-based sample of 20 families (20 TGD youth, ages 7 to 18 years, and 34 caregivers) from 3 U.S. geographic regions. TGD youth represented multiple gender identities; caregivers included mothers (n = 21), fathers (n = 12), and 1 grandmother. Each family member completed an individual semistructured interview that included questions about family relationships. Interviews were transcribed verbatim and transcripts were analyzed using a thematic analysis approach. Analyses revealed complex bidirectional family relationships, highlighting 5 contextual factors influencing these relationships: school, community, workplace, religion, and extended family. TGD youths' identity development was inextricably linked to how caregivers respond to, adjust to, and learn from their children, and how caregivers interact with one another. Findings illustrate how caregiver acceptance and family cohesion may be linked and how youth and caregivers identified shared contextual factors impacting the family system. This research highlights the importance of situating TGD youth and caregivers as equal partners in family level approaches to affirm and support TGD identity development. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Suicide and the transgender experience: A public health crisis.

Given the rise in the visibility of the trans community, increasing attention has been paid to mental health disparities in trans populations. Specifically, research findings conclude that suicide is considered 1 of the major health disparities in trans populations. Across several studies it has been found that 40% or more of trans people have attempted suicide at least once in their lifetime. There are a multitude of reasons why trans people experience suicidal ideation and attempt suicide, with minority stress being theorized as a primary cause. To address minority stress-focused suicide, a psychologically adapted public health model is proposed. This model includes the following steps for preventing suicidal thoughts and behaviors: (a) defining the issue, (b) identifying causes and risk factors, (c) developing and testing psychological interventions, and (d) implementing psychological interventions. Key components discussed include the evidence and practice for supporting trans people through their social and medical transition processes, which have been demonstrated to improve mental and physical health outcomes. The implications of the prevention model indicate that psychologists play a key role in supporting trans people, regardless of the clinical concerns that bring them to therapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Minority stress and health: A grounded theory exploration among men who have sex with men in China and implications for health research and interventions.

RATIONALE: Men who have sex with men (MSM) in China are disproportionately affected by HIV and mental health issues. Although predominately western-based research suggests a minority stress perspective to explain health disparities, how Chinese MSM experience stress related to being a sexual minority and how such experiences affect their health have not been carefully examined. OBJECTIVE: This study was a qualitative investigation of how stress related to sexuality (e.g., stigma, discrimination, and oppression) are experienced among MSM in China and how these experiences affect their psychological and behavioral health. METHOD: In-depth, semi-structured interviews were conducted with 24 MSM in China. Grounded theory was employed to guide data analysis. RESULTS: Six categories emerged, which included: A Family-Oriented, Heteronormative Culture, Interpersonal Rejections and Marginalization, Internalization of Stigma, the Psychological Impact of Minority Stress, Impact on HIV-related Behavioral Health, and Coping. A conceptual model was developed, which illustrated relationships among categories and described sources, processes, and impact of minority stress among MSM in China. Cultural, social, and internalized sources of minority stress were shown to have detrimental effects on participants' psychological health and HIV-related behavioral health. Various coping strategies shared the purpose of navigating well-being in one's direct environment and in the larger culture. CONCLUSIONS: Findings demonstrate the relevance of minority stress in behavioral health among Chinese MSM as well as the need to conceptualize minority stress within MSM's sociocultural context. HIV prevention efforts may benefit from a contextualized understanding of minority stress and addressing minority stress in a culturally congruent, community-centered fashion.

Psychotherapy research is needed to improve clinical practice for clients with HIV.

This introductory article to the special issue on psychotherapy and HIV provides an overview of the state of HIV intervention research, recommendations for future psychotherapy practice, and an emphasis on how psychotherapy researchers focusing on HIV should move away from the typical public health model. We provide information about how historical bias impacts HIV clinical decision-making now. In addition, we include an analysis of how public health definitions of intervention research have limited psychotherapy research-specifically the importance of common factors and process-oriented components in psychotherapy. In this introductory article, we highlight the 13 articles that comprise the 5 following sections included in the special issue: (a) General Guidelines for Psychotherapy Practice for People With HIV, (b) HIV Stigma in Psychotherapy Process and Techniques, (c) Sexual Functioning and Romantic Relationships for People with HIV, (d) A Focus on Specific Disorders (Chronic Pain and Trauma) Comorbid With HIV, and (e) A Focus on Specific Populations (Adolescents and South African Populations). We conclude by offering recommendations to researchers to focus on the sociocultural context for clients with HIV and for psychotherapists to use an intersectional approach in their work with clients with HIV. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

At the Margins: Comparing School Experiences of Nonbinary and Binary-Identified Transgender Youth.

BACKGROUND: Transgender, nonbinary, and gender nonconforming (TNG) young people are a diverse group, including young people with gender identities beyond the gender binary. Whereas nonbinary youth experience disparities in victimization and mental health, school belonging, support, and resources have not been well described. METHODS: We conducted an online survey of TNG young people (ages 12-22) in Wisconsin to assess school belonging, safety, support, and resources. We compared responses among participants with nonbinary versus binary identities using mulvariate analysis of variance, multivariate analysis of covariance, chi-square and logistic regression analysis. RESULTS: A total of 287 TNG young people met inclusion criteria (average age 18.2 ± 2.5 years). More than 40% of participants identified as nonbinary. Nonbinary participants were less likely to be out to teachers, but more likely to utilize supportive staff as a resource compared to binary-identified TNG peers. There were no significant differences in school safety and belonging. CONCLUSIONS: Most school experiences do not vary significantly between TNG young people with binary versus nonbinary gender identities, though nonbinary young people are less likely to be out at school. Future research should examine factors that impact whether nonbinary young people share their gender identity and access school support services.

Toward a psychotherapy science for all: Conducting ethical and socially just research.

Much has been written in recent years regarding the integration of social justice values with psychology and psychotherapy; however, the discourse surrounding social justice perspectives related to conducting psychotherapy research is scant. Psychotherapy researchers are beholden to various professional ethical standards, laws, and policies; however, adhering to these rules and guidelines may make research ethical, but not necessarily socially or politically just. In this article, the authors build on previous work from community, feminist, positive, and multicultural psychology perspectives as well as their own experiences as psychotherapy researchers, to propose a framework for approaching psychotherapy research from an ethical and socially just position. Examples from the authors' experiences conducting psychotherapy research with incarcerated individuals, community- and school-based research with youth, and research with sexual/gender minorities are provided to illustrate theoretical principles and provide practical recommendations. Barriers to implementing such a framework to psychotherapy research, as well as strategies to manage these challenges are also discussed. In addition, the authors propose a model that can be used to develop and evaluate the social justice process and content dimensions of a research study. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Inequalities in Crowdfunding for Transgender Health Care.

Purpose: An emerging body of research analyzes the scope, ethics, and inequalities of web-based crowdfunding to raise money for medical expenses related to illness or injury. To date, little research has investigated how transgender communities utilize crowdfunding expenses related to gender affirming medical care. Methods: Using GoFundMe.com, we created a data set of 391 crowdfunding campaigns for gender-affirming care created from 2012 to 2016. In addition to descriptive statistics of recipient demographics and campaign financials, we conducted hierarchical multiple regression analyses to determine the factors associated with financial outcomes of fundraising for medical expenses. Results: Findings indicate that the majority of campaigns were used to fund chest surgeries among young, white, binary-identified trans men in the United States. Few campaigns met their fundraising goal. Being a trans man whose Facebook community shares the crowdfunding campaign is predictive of meeting a higher percentage of the fundraising goal, whereas being a trans woman whose Facebook community shares the campaign is predictive of raising more money. Conclusion: The use of crowdfunding for gender affirming highlights the difficulties that transgender persons face with using private and public health care programs to fund medically necessary care. Health care providers should exercise caution in recommending crowdfunding as a viable strategy to raise money for out-of-pocket costs.

Attending to gender in psychotherapy: Understanding and incorporating systems of power.

This study reviews the research evidence on the effectiveness of attending to clients' gender identity and gender as a system of power in psychotherapy. We begin with definitions and measures of gender identity and provide clinical examples. Next, we summarize our search for studies to conduct two meta-analyses on: (a) randomized controlled trials (RCTs) of psychotherapy conducted with transgender clients, and (b) RCTs of the outcomes of psychotherapies that attend explicitly to gender as a system of power compared with another bona-fide psychotherapy. Our search did not yield studies that fit either search criteria; thus, meta-analyses were not conducted. Instead, we conducted a content analysis of the 10 qualitative and quantitative studies on psychotherapy with transgender individuals. We conclude by highlighting the limitations of the research base, describing diversity considerations, and recommending therapeutic practices that attend to gender, gendered systems of power, oppression, and privilege.

Engaging in LGBQ+ affirmative psychotherapies with all clients: Defining themes and practices.

The clinical need for lesbian, gay, bisexual, and queer (LGBQ+) affirmative psychotherapies has been widely recognized; however, empirical research on the outcomes of such psychotherapies is limited. Moreover, key questions about whom such psychotherapies are for and what they comprise require critical consideration. We begin by offering definitions to answer these questions and delineate four key themes of LGBQ+ affirmative psychotherapies. We conceptualize LGBQ+ affirmative psychotherapies not as sexual orientation group-specific, but rather as considerations and practices that can be applied with all clients. We then summarize our own search for studies to attempt a meta-analysis and we discuss limitations and directions for research based on our literature review. We end by delineating diversity considerations and recommending therapeutic practices for advancing LGBQ+ affirmative psychotherapy with clients of all sexual orientations.

Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review.

OBJECTIVE: Alliance, empathy, and genuineness are each integral parts of the therapeutic relationship. No previous meta-analysis has explored the extent to which therapist empathy and genuineness contribute to the therapeutic alliance. METHOD: In this meta-analysis, a multifaceted search strategy yielded 53 studies. Forty studies reported alliance/empathy relationships, eight studies reported alliance/genuineness relationships, and five studies reported both. RESULTS: Random effects meta-analyses revealed that therapeutic alliance was significantly related to perceptions of therapist empathy with a mean r = 0.50 (95% CI = 0.42, 0.57). Therapeutic alliance was also significantly related to perceptions of therapist genuineness with a mean r = 0.59 (95% CI = 0.45, 0.71). Tests of publication bias indicated a low likelihood of publication bias affecting the strength and direction of the results. Potential moderating variables were explored, including rater perspective, measure of therapeutic relationship variables, and client race/ethnicity. CONCLUSIONS: Therapeutic alliance has a moderate relationship with perceptions of therapist empathy and genuineness. Of note, there may be reason to believe that when rated by the same person, these constructs have significant overlap and lack discreteness. Future directions for study of the therapeutic relationship are discussed. Implications for practice are provided.

Longitudinal Associations of Sexual Fluidity and Health in Transgender Men and Cisgender Women and Men.

Research has just begun to study associations between sexual fluidity and health among cisgender individuals; only one cross-sectional study examined these links among transgender individuals. The goals of the current study were to prospectively examine fluidity in sexual attractions and fluidity in sexual orientation identity, and associations with health-related outcomes. Participants were a community-based sample of 45 transgender men, ages 16-51 years, who had recently begun testosterone, and 95 cisgender individuals (53 women, 42 men), ages 18-55 years, who completed surveys either in-person or via mail. Analyses tested for group differences in sexual fluidity, sociodemographic predictors of sexual fluidity among transgender men, and associations between sexual fluidity and health across the three groups. As hypothesized, transgender men reported more fluidity in sexual attractions and sexual orientation identity than did cisgender individuals. Contrary to our hypotheses, testosterone use was not significantly associated with sexual fluidity, although less education was. As hypothesized, fluidity in sexual orientation identity was associated with more adverse mental health outcomes among transgender men (depression and anxiety) and cisgender women (anxiety and stress), as well as decreased vitality among transgender men and cisgender women, and decreased social functioning among cisgender women. In contrast, fluidity in sexual attractions was only associated with less depression among cisgender women, but was not significantly associated with any other health-related outcomes. This study increases knowledge about sexual fluidity among transgender men and implications for health and can inform clinical work with this population.

Introduction to special section on advanced methodology: Counseling the dog to wag its methodological tail.

In this article, we introduce a special section focused on the application of advanced methodologies to specific research questions in counseling psychology. The articles include applications of natural language processing, dynamic systems, mediation analyses in single studies and meta-analysis, and synthesis of qualitative research. We provide a brief overview of each article. (PsycINFO Database Record