Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States.

The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.

The Often-Circuitous Path to Affirming Mental Health Care for Transgender and Gender-Diverse Adults.

PURPOSE OF REVIEW: We describe recent research regarding access to affirming mental health services for transgender and gender-diverse (TGD) adults and explore new resources available for therapists to inform evidence-based practice with TGD clients. RECENT FINDINGS: Barriers and facilitators at all socioecological levels impact TGD adults' mental health help-seeking. TGD adults often interface with mental health providers while accessing gender-affirming medical care, though new standards of care are likely to alter this typically common path to mental health services. Efforts to improve therapist education, such as therapy manuals, are increasingly available and a necessary step to increase the number of competent, affirming therapists. More work-both advocacy and research-is needed to fully expand accessible, affirming mental health services for TGD adults. Better understanding factors impacting different steps of the mental health help-seeking process and conducting randomized controlled trials of affirming mental health services are important next steps.

Transgender and gender diverse adults' self-reported mental health diagnoses, engagement in mental health services, and perceptions of therapists.

OBJECTIVE: Transgender and gender diverse (TGD) people face various challenges when seeking therapy. Given this, we wanted to understand more about TGD people's perceptions of providers and how these compare to researcher ratings of providers on metrics of affirming practice. METHOD: The sample included 158 TGD adults (Mage = 33.06); 57.6% were in therapy. Participants completed measures about mental health, resilience, and therapy. We systematically coded provider websites and intake forms. RESULTS: Participants in therapy were older, had higher depression, and lower resilience than participants not in therapy. Non-binary/genderqueer participants rated providers as less knowledgeable compared to trans feminine participants. Overall, participants appeared satisfied (71.4% extremely satisfied) and viewed providers as at least moderately knowledgeable (89.1%). Provider coding revealed variation across the markers of affirmation; 66.04% identified a TGD-specialty and only 26.42% shared provider pronouns. Higher frequency of inclusivity (via coding) was related to higher ratings of provider knowledge and more of a focus on gender, however, there was not a significant association with satisfaction. CONCLUSIONS: Providers who engaged in more affirming practices were more knowledgeable compared to those who engaged in fewer affirming practices. This may influence the content of therapy and whether clients feel comfortable discussing gender.

Bridging the Gap Between Practice Guidelines and the Therapy Room: Community-Derived Practice Adaptations for Psychological Services with Transgender and Gender Diverse Adults in the Central United States.

Individuals who identify as transgender or gender diverse (TGD) are presenting at mental health clinicians' offices with increasing frequency. Many TGD clients are seeking care related to affirming their gender identity but also may present with anxiety, depression, trauma, substance abuse, or other problems for which a clinician may commonly provide services. Some clinicians may hesitate to accept TGD clients into their practice if they have little specialized training to work with this population in an affirming manner, especially in more underserved areas where a generalist practice is the norm. Numerous professional associations and experts have developed guidelines for affirmative behavioral health care for TGD people. However, what is needed are community informed recommendations to bridge from the official guidelines to clinicians' in-session activities. The Trans Collaborations Practice Adaptations for Psychological Interventions for Transgender and Gender Diverse Adults are derived from iterative interviews with TGD community members and affirming mental health clinicians in the Central United States. The 12 practice adaptations are intended to guide clinicians to adapt their usual treatment approach to be TGD affirming, especially in underserved and rural areas. The practice adaptations cover numerous aspects of practice including the office setting and paperwork, understanding gender identity and incorporating it into the case conceptualization, therapist's self-awareness, and referrals. The Trans Collaborations Practice Adaptations will help clinicians work confidently and competently with adult TGD clients, regardless of the presenting problem, to ensure TGD communities receive the best interventions for their behavioral health concerns.

Unmet Expectations in Health Care Settings: Experiences of Transgender and Gender Diverse Adults in the Central Great Plains.

Transgender and gender diverse (TGD) individuals face a long-term, multifaceted process if they choose to begin a gender affirmation journey. Decisions to go on hormone therapy and/or have a surgical procedure necessitate the TGD individual to set up an appointment with a health care provider. However, when TGD patients interact with health care practitioners, problems can arise. This article documents and categorizes the types of unmet expectations that are common in the TGD patient-health care provider social dynamic in the Central Great Plains of the United States. Utilizing a community-based participatory research model, qualitative in-depth interviews were conducted with 27 TGD individuals about their health care experiences. From this, the researchers identified four main themes of unmet expectations: probing, gatekeeping, stigmatizing stance, and misgendering/deadnaming. Steps that can be taken by both the health care provider and the TGD individual to have a more successful encounter are discussed.

Are we certain about which measure of intolerance of uncertainty to use yet?

Intolerance of Uncertainty (IU) has been understood as a dispositional tendency to view the presence of negative events as unacceptable and threatening, regardless of the likelihood of those events occurring. The preference over the 12-item vs. 27-item of the IUS has been central to debate. The goals of the present study were to evaluate two competing models of measuring IU with model-fitting analyses and explore model invariance of gender (e.g. men vs. women). A sample of 980 individuals completed an online IUS survey. Results indicated that the two-factor short-form model provided better fit to the data compared to the full-length two-factor model proposed by. Results also indicated that the short-form IUS is gender invariant, suggesting acceptable use among men and women. These findings provide further support of a two-factor structure and suggest that the IUS is appropriate for men and women.

The Effects of Social Anxiety and State Anxiety on Visual Attention: Testing the Vigilance-Avoidance Hypothesis.

A growing theoretical and research literature suggests that trait and state social anxiety can predict attentional patterns in the presence of emotional stimuli. The current study adds to this literature by examining the effects of state anxiety on visual attention and testing the vigilance-avoidance hypothesis, using a method of continuous visual attentional assessment. Participants were 91 undergraduate college students with high or low trait fear of negative evaluation (FNE), a core aspect of social anxiety, who were randomly assigned to either a high or low state anxiety condition. Participants engaged in a free view task in which pairs of emotional facial stimuli were presented and eye movements were continuously monitored. Overall, participants with high FNE avoided angry stimuli and participants with high state anxiety attended to positive stimuli. Participants with high state anxiety and high FNE were avoidant of angry faces, whereas participants with low state and low FNE exhibited a bias toward angry faces. The study provided partial support for the vigilance-avoidance hypothesis. The findings add to the mixed results in the literature that suggest that both positive and negative emotional stimuli may be important in understanding the complex attention patterns associated with social anxiety. Clinical implications and suggestions for future research are discussed.

Mental Health and Marginalization Stress in Transgender and Gender Diverse Adults: Differences between Urban and Non-Urban Experiences.

Background: Transgender and gender diverse (TGD) individuals face high rates of psychological distress, including depression, anxiety, and suicide risk. Further, TGD individuals living outside of urban areas experience additional disparities compared to their urban counterparts. Minority stress theory states that minority stressors (termed marginalization stressors for this paper), such as experiences of discrimination and internalized transphobia, lead to psychological distress. The current study compared marginalization stressors across rural (population less than 2,500), urban cluster (population between 2,500 and 50,000), and urban (population greater than 50,000) samples and tested the degree to which these stressors account for differences across areas of residence. Methods: Participants were 225 TGD individuals who completed an online survey that included measures of depression, anxiety, suicidal ideation marginalization stress, and protective factors. Results: In the first model, mental health outcomes, marginalization stressors, and protective factors differed between areas. Urban cluster participants reported experiencing higher levels of depression, anxiety, and suicidal ideation and rural participants reported experiencing higher levels of depression suicidal ideation than urban participants. Both rural and urban cluster participants reported more experiences of several marginalization stressors. In the subsequent path model, indirect effects between area and marginalization stress variables were significant, but urban cluster participants still reported higher depression, anxiety, and suicidal ideation symptoms (p-values < .05). Discussion: We demonstrate that marginalization stress processes appear to account for some of the differences between TGD individuals living in urban, rural, and urban cluster areas. The differences between areas largely persist, however, after controlling for marginalization stress, especially when comparing urban with urban cluster areas.

Transgender and Gender-Diverse People's Experiences of Minority Stress, Mental Health, and Resilience in Relation to Perceptions of Sociopolitical Contexts.

Purpose: The sociopolitical context in which transgender and gender-diverse (TGD) people live has significant effects on mental health. We examined whether perceptions of context (TGD people's perceptions of how TGD people were viewed) differed across four United States (U.S.) states and associations with mental health and identity pride, the mediational effects of minority stressors, and potential buffering effects of resilience. Methods: TGD individuals in Oregon, Michigan, Nebraska, and Tennessee (n=158; ages 19-70, mean=33.06) completed questionnaires assessing their perceptions of how TGD people were viewed in their local area and in the U.S., as well as scales assessing minority stressors, pride, resilience, and mental health. Data were collected during Fall 2019 to Spring 2020. Results: Oregon participants viewed perceptions in their state the most positively, with no state-level differences in terms of broader U.S. perceptions. Tennessee participants experienced more expectations of rejection; however, there were no differences across the states in other minority stress variables, identity pride, resilience, or mental health. Participants who viewed their area as having more negative views of TGD people reported higher levels of discrimination, expectations of negative events, internalized stigma, and anxiety, as well as less pride. The effects of perceptions of local context on mental health were partially explained by enacted stigma and internalized stigma. Resilience did not buffer the effects of perceptions of the local context on mental health or pride. Conclusion: Context is important to shaping exposure to minority stressors and mental health, potentially through increasing enacted and internalized stigma.

Revisiting the Rainbow: Culturally Responsive Updates to a Standard Clinical Resource.

PURPOSE: Cultural responsivity is essential for efficacious and affirming clinical relationships. This may be especially important with historically marginalized clients, such as transgender and gender-diverse (TGD) people seeking behaviorally based affirming communication services. We recommend modifications to standard tools for diagnostics and training that otherwise might undermine our efforts to create an inclusive and affirming environment. METHOD: Modifications to the Rainbow Passage, a standardized paragraph utilized for eliciting speech samples in clinical settings, focused on nongendered terminology and the elimination of content with religious connotations. RESULTS: The recommended edits to the Rainbow Passage maintain similar length, cadence, and phonetic balance while considering cultural and health care context for TGD people and other clients. CONCLUSION: Simple linguistic changes to a standardized paragraph maintain clinical benefits and facilitate SLP efforts toward cultural responsivity, client engagement, and good clinical outcomes.

Educational preparedness to care for transgender and gender diverse adults: Perspectives of mental health professionals.

Ensuring that mental health professionals are appropriately trained to provide affirming and sensitive care to transgender and gender diverse (TGD) adults is one mechanism that may reduce the marginalization sometimes experienced by TGD adults in mental health contexts. In this study, mental health professionals (n=142) completed an online survey documenting the sources and types of training received to provide TGD-sensitive care; and, shared a self-assessment of their comfort, competence, and ability to provide TGD-sensitive care. Findings revealed that the majority of the mental health professionals in the study (approximately 81%) received specific training to work with TGD clients from a variety of sources. These mental health professionals also self-reported high levels of comfort, competence, and ability to offer TGD-sensitive care which were statistically significantly associated with the number of hours of TGD-specific training they had received.

Transgender and Gender Diverse Community Perspectives on Barriers and Benefits of the Psychosocial Assessment for Gender-Affirming Medical Care.

Transgender and gender diverse (TGD) individuals often must undergo a psychosocial assessment and receive a letter of support from a mental health care provider to access gender-affirming medical care (GAMC). This study describes TGD individuals' perceptions of barriers and benefits of the assessment process and uses thematic analysis to explore TGD individuals' opinions on how mental health care should or should not be related to gender-affirming medical care. Two hundred and eighteen TGD participants completed an online survey. Participants endorsed benefits and negative impacts associated with the psychosocial assessment and provided qualitative responses to explain their support or opposition to involvement of mental health care and assessment in accessing GAMC. Nearly all participants identified both benefits (e.g., "experienced validation") and barriers (e.g., "experienced an increase in psychological distress") to the psychosocial assessment. Results are considered in the context of the historical marginalization and gatekeeping of TGD people by the medical system.

Correlates of same-sex attractions and behaviors among self-identified heterosexual university students.

Few studies have focused on intragroup variations in sexual orientation and fewer on self-identified heterosexuals with same-sex attractions, fantasies, and/or behaviors. Self-identified heterosexual students at a large public midwestern university (N = 263) completed measures of sexuality and gender, attitudes toward lesbian, gay, and bisexual (LGB) people, religious and political beliefs, emotional well-being, and demographics. The sample included 82 individuals (31%; labeled "H+") who endorsed same-sex attraction, fantasy, and/or behavior and 181 (69%; labeled "H") who did not. Women were more likely to be categorized as H+ than men. H+ participants had more positive attitudes toward lesbians and gay and bisexual men and reported more support for LGB-positive public policies than did H participants. H+ participants reported less literalistic beliefs about religious scripture than did H participants. H and H+ groups did not differ significantly on measures of emotional well-being. Results were discussed in the context of recent literature arguing for a more nuanced and gender-differentiated approach toward assessing sexual orientation, as well as literature on the flexibility of sexual orientation and on heterosexual identity development.

Trans and Gender Diverse People's Experience Wearing Face Masks During the COVID-19 Pandemic: Findings from Data Across 4 States in the USA.

Introduction: Social isolation and reduced access to public life in response to SARS-CoV-2 (COVID-19) challenges health and well-being for many. Marginalized communities, including transgender and gender diverse (TGD) people, have been disproportionally impacted. Experiences of TGD people should be centered in pandemic-related research to better inform policy. Methods: A diverse sample of TGD people (N = 158) were recruited from Michigan, Nebraska, Oregon, and Tennessee to participate in the Trans Resilience and Health Study. Participants ranged from 19 to 70 years old (M = 33.06; SD = 12.88) with 27.2% identifying as trans men/men, 26% identifying as trans women/women, and remaining identifying with terms like genderqueer and nonbinary. Thirty percent identified as people of color. Participants completed a monthly COVID-19-related questionnaire April 2020-March 2021 including open-ended questions to learn what contributed to resilience during this time. Thematic analyses of responses enabled identification of salient themes. Results: Analyses revealed pandemic-related changes in social experiences of marginalization and mask-wearing. Twenty-six participants mentioned face masks as contributing to resilience while also elaborating the influence of masks on experiences of misgendering. Participants identifying as trans women reported decreased misgendering while trans men and nonbinary participants reported increased misgendering. Conclusions and Policy Implications: Mask-wearing helps reduce transmission of COVID-19. For some trans women, masks also reduce the threat of misgendering and possibly other forms of enacted stigma. However, increased risk for misgendering, as noted by trans men in our study, should be considered and increased supports should be provided.

Cognitive-Behavioral Therapy for Immigrants Presenting With Social Anxiety Disorder: Two Case Studies.

Cognitive-behavioral therapy (CBT) for the treatment of Social Anxiety Disorder (SAD) has demonstrated efficacy in numerous randomized trials. However, few studies specifically examine the applicability of such treatment for ethnic minority clients. Thus, the purpose of this article is to present two case studies examining the utility of individualized CBT for SAD with two clients who immigrated to the United States, one from Central America and one from China, for whom English was not their primary language. Both clients demonstrated improvement on a semi-structured interview and self-report measures. Necessary adaptations were modest, suggesting that therapy could be conducted in a culturally sensitive manner without much deviation from the treatment protocol. Results are discussed in terms of adapting treatment to enhance acceptability for and better fitting the needs of ethnic minority clients and non-native speakers of English. Implications for treating ethnic minority clients, as well as the practice of culturally sensitive treatment, are discussed.

A Systematic Review of Recommendations for Behavioral Health Services for Transgender and Gender Diverse Adults: The Three-Legged Stool of Evidence-Based Practice is Unbalanced.

There is a growing literature of clinical recommendations for transgender and gender diverse (TGD) affirming behavioral health care, yet it is unknown to what extent these recommendations are rooted in evidence-based practice (EBP). This systematic review included 65 articles published between 2009 and 2018 with recommendations for behavioral health services with TGD adults, emphasizing general clinical care. Coded variables included type of article, participant demographics, aspects of EBP, and whether care was informed by objective assessment. Most articles did not equally draw from all components of EBP. Recommendations for specific clinical problems are increasingly available and address diversity within TGD communities. More research, including clinical trials adapting established interventions, is needed to inform state-of-the-art TGD-affirmative behavioral health care.

Specialists in Name or Practice? The Inclusion of Transgender and Gender Diverse Identities in Online Materials of Gender Specialists.

Recommendations for health care providers working with transgender and gender diverse (TGD) individuals emphasize affirming clients' identities, such as using correct pronouns and name, however it is unknown how often gender specialists adhere to such recommendations. Websites and intake forms of gender specialists were coded for use of affirming language, asking for pronouns and chosen name, and mention of TGD specialties and resources. Most websites identified the provider's specialty to work with TGD individuals, though much fewer provided additional resources concerning TGD issues and only half of intake forms included affirming language. Given previous research that has demonstrated providers working in states with legal protections for TGD individuals use affirming language more often than providers in locales without protections, association with state legal climate is also examined.

The provider perspective on behavioral health care for transgender and gender nonconforming individuals in the Central Great Plains: A qualitative study of approaches and needs.

Transgender and gender nonconforming (TGNC) individuals interact with mental health care systems at high rates and experience substantial barriers to care. Rural TGNC individuals face additional disparities in accessing appropriate mental health services. Little research has focused on the mental health care providers who work with TGNC individuals in underserved areas. The current study sought to describe the mental health care services delivered by providers perceived as affirming by TGNC community members in the Central Great Plains. We conducted qualitative interviews with 10 providers to understand how providers seek cultural competency and conceptualize and work with their TGNC clients given the barriers to care. Providers held diverse theoretical orientations and described challenges to working with TGNC clients, including the impact of stigma and marginalization and financial and structural barriers to care. Emphasis was placed on individualizing care, helping clients to manage stigma and build resiliency, connecting clients to resources (when available) and support systems, and navigating the intersections of physical health care and mental health care, such as writing letters for medical transition. Providers largely educated themselves on TGNC topics and had previous experience working with marginalized populations. Overall, the providers' approaches to working with TGNC clients mapped onto models of cultural competency, but few providers described their work in the context of an evidence-based model. Implications for increasing the quality and availability of mental health care services for TGNC individuals in underserved areas are discussed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The relationship among social phobia, objective and perceived physiological reactivity, and anxiety sensitivity in an adolescent population.

Physiological theories may be important in the development and maintenance of social phobia in youth. A limited literature base indicates that youth with social phobia experience increases in objective physiological arousal during social-evaluative situations and are more aware of such increases compared to nonanxious youth. Recent research suggests that youth with social phobia also evidence heightened levels of anxiety sensitivity, which may lead to interpretation of physiological arousal as dangerous or distressing, and, as a result, in avoidance of situations which produce increased physiological arousal. The purpose of the current study was to examine interaction among objective physiological arousal, perceived physiological arousal, and anxiety sensitivity among adolescents diagnosed with social phobia. A sample of community adolescents participated in two anxiety-provoking tasks during which objective physiological arousal was monitored, and after which perceived physiological arousal and anxiety sensitivity were evaluated. Results from this study evidenced no differences between social phobic and nonanxious adolescents with regard to objective physiological arousal during either anxiety-provoking tasks. Adolescents with social phobia, however, were more aware of measured increases in physiological arousal, as well as more afraid of the potential social implications of that arousal compared to nonanxious adolescents. Implications for theory and treatment are discussed.

Cognitive-behavioral approaches to the treatment of social anxiety disorder.

The current paper provides an overview of and evidence for the cognitive-behavioral formulation of social anxiety. In addition, the paper presents the theory supporting an empirical basis for the use of exposure and cognitive restructuring in the treatment of social anxiety disorder. Finally, the paper concludes with a review of the effectiveness of cognitive-behavioral treatments for social anxiety disorder, including a comparison with psychopharmacological treatments. Both cognitive-behavioral and pharmacological interventions appear to be effective for social anxiety disorder, with relative advantages and disadvantages for each.