The gender minority stress model and/or cisnormativity? The need for pluralistic theoretical perspectives in improving trans health and medicine.

The minority stress model has become a well-used framework to explain and analyse health among LGBTQ people, and specifically among transgender and gender-diverse people (TGD), when it is sometimes called 'the gender minority stress model'. Scholars have argued the need for critical discussions about some of the assumptions underlying the gender minority stress model and how it has been used and discussed. Drawing on a pluralistic understanding of theories and employing a Foucauldian understanding of critique, we discuss implicit assumptions and epistemological standpoints of the gender minority stress model and the connected limitations. We also ask what the concept of cisnormativity can give rise to in comparison with the minority stress framework. We make four arguments: 1) the calls for extensions to the model could be seen as a desire to understand and analyse TGD people's health from an all-encompassing perspective, resulting in theoretical vagueness and the silencing of excluded aspects; 2) in the gender minority stress literature, identity is largely taken for granted and there is no consideration of how power is constitutive for all subjects; 3) the model risks individualising the effects of social norms, and internalisation could be further theoretically developed in relation to the repression hypothesis; 4) in the translation process from LGB minorities to TGD, as well as in thinking about cisnormativity, the issue of gender-affirming care has largely been neglected. By initiating a critical discussion around these issues and illustrating how different theories and frameworks can illuminate different possibilities for thinking and knowing, we aim to open up new routes for thinking about TGD health and medicine.

Psychometric Exploration of the Swedish Translation of the Sexual Orientation Microaggressions Scale (SOMS), and a Commentary on the Validity of the Construct of Microaggressions.

The aim of the present study was to assess the psychometric properties of a Swedish translation of the Sexual Orientation Microaggressions Scale (SOMS) in a convenience sample of 267 Swedish LGB+ people (Mean age = 36.41). Testing suggested some strengths in terms of factor structure and 2-week test-retest reliability (ICC > .79). Also, internal consistency (α = .80-.91) and convergent validity were supported for most subscales. However, the Assumption of Deviance subscale was associated with low response variability and internal consistency (α = .35), and the correlational pattern between the Environmental Microaggressions subscale and mental health variables diverged from the overall trend. Furthermore, measurement invariance between homo- and bisexual participants was not supported for most subscales, and although microaggressions would be theoretically irrelevant to a small comparison sample of heterosexual people (N = 76, Mean age = 40.43), metric invariance of the Environmental Microaggressions subscale was supported in comparison to LGB+ people. We argue that these limitations suggest a restricted applicability of the SOMS in a Swedish context, and this has consequences for the definition and operationalization of the construct of microaggressions as a whole. Therefore, more research on the latent properties of microaggressions in Swedish as well as in other contexts is required.

Supporting Well-Being in Gender-Diverse People: A Tutorial for Implementing Conceptual and Practical Shifts Toward Culturally Responsive, Person-Centered Care in Speech-Language Pathology.

PURPOSE: Gender dysphoria is commonly conceptualized as a mental disorder in gender-diverse people who do not identify with the gender assigned to them at birth. Direct support for well-being tends to be delegated to the field of mental health (MH), whereas speech-language pathology (SLP) practice is charged with modifying gender-diverse people's voice and communication in the belief that well-being will improve as a byproduct. However, with the introduction of the minority stress model, gender dysphoria is now understood as the result of sociocultural processes of stigmatization, pathologization, coping, and resilience, and it is to be addressed by all professions providing transgender health services. The purposes of this tutorial are to examine practices in SLP in light of the current conceptualization of gender dysphoria and guide speech-language pathologists in their role in supporting the well-being of gender-diverse people. METHOD: We reviewed the SLP and MH literature in the topic area to compare the two disciplines' conceptualizations and approaches to professional support for gender-diverse people. RESULTS: We propose a transdisciplinary, person-centered, and culturally responsive approach to SLP practice that directly attends to minority stress, microaggressions, coping skills, and resilience factors. CONCLUSIONS: It is not sufficient for speech-language pathologists to delegate support for well-being in gender-diverse people to MH practitioners. Rather, speech-language pathologists need to be proactive in taking responsibility for supporting their clients' well-being based on each individual clinician's knowledge, skills, and capacity to do so. We recommend addressing barriers and facilitators of gender-diverse people's well-being both within SLP as a professional culture and by adapting the clinician's own professional practice.

"What I couldn't do before, I can do now": Narrations of agentic shifts and psychological growth by young adults reporting discontinuation of self-injury since adolescence.

PURPOSE: We explore young adults' narrations of life events in association with nonsuicidal self-injury (NSSI) discontinuation, psychological growth, and agency. METHODS: Transcripts from eleven face-to-face interviews with individuals who quantitatively reported injuring themselves in adolescence (2007-2008) but not in young adulthood (2017) were narratively analysed. RESULTS: We found that at starting points, a period preceding an agentic shift in the narrative, participants endured stressful living conditions and mental illness. During this period, participants perceived no point in trying to initiate change because they did not perceive themselves as having the capacity to do so and nor could they adequately utilize any formal or informal support. After a turning point that enabled agency due to gaining a sense of belongingness, liberation, or perspective, participants underwent a process of attaining psychological well-being. However, narrating psychological growth also required momentum points, encompassing the management of and moving on from stressful contexts, along with the recognition of milestones marking improvement relative to the starting points. CONCLUSIONS: NSSI discontinuation was narrated in conjunction with psychological growth when participants also experienced themselves as situated within an agentic context, because agency is understood as necessary to react to and manage current and future life circumstances.

Clitoral surgery on minors: an interview study with clinical experts of differences of sex development.

OBJECTIVES: Clitoral surgery on minors diagnosed with differences of sex development is increasingly positioned as a violation of human rights. This qualitative study identified how health professionals (HPs) navigate the contentious issues as they offer care to affected families. DESIGN: Qualitative analysis of audio-recorded semistructured interviews with HPs. All of the interviews were transcribed verbatim for theoretical thematic analysis. SETTING: Twelve specialist multidisciplinary care centres for children, adolescents and adults diagnosed with a genetic condition associated with differences of sex development. PARTICIPANTS: Thirty-two medical, surgical, psychological and nursing professionals and clinical scientists in 12 specialist centres in Britain and Sweden formed the interview sample. RESULTS: All interviewees were aware of the controversial nature of clitoral surgery and perceived themselves and their teams as non-interventionist compared with other teams. Data analyses highlighted four strategies that the interviewees used to navigate their complex tasks: (1) engaging with new thinking, (2) holding on to historical assumptions, (3) reducing the burden of dilemmas and (4) being flexible. In response to recent reports and debates that challenge clitoral surgery on minors, HPs had revised some of their opinions. However, they struggled to reconcile their new knowledge with the incumbent norms in favour of intervention as they counsel care users with variable reactions and expectations. The flexible approach taken may reflect compromise, but the interviewees were often trapped by the contradictory values and assumptions. CONCLUSIONS: If the pathology-based vocabularies and narratives about genital diversity could be modified, and normative assumptions are questioned more often, clinicians may be more adept at integrating their new knowledge into a more coherent model of care to address the psychosocial concerns that genital surgery purports to overcome.

Key Push and Pull Factors Affecting Return to Work Identified by Patients With Long-Term Pain and General Practitioners in Sweden.

Research shows that working is positive for people with long-term pain but that work-related support from health professionals is inadequate. One explanation for this inadequacy is that patients and providers differ in terms of perspectives on motivation to work. In this article, we compare factors that 31 patients and 15 general practitioners consider important to promote return to work for people with long-term pain. We analyzed the interviews with thematic analysis and a motivational push and pull framework to cover different motivational factors, societal and individual, that might push or pull patients from or toward work. Providers said that a difference between working and nonworking patients is their level of individual motivation, while the patients' stories showed that the main difference was the physical (non)ability to push themselves to work. We suggest that work-related support can be improved by addressing such differences in clinical practice.

From Knowing Nothing to Knowing What, How and Now: Parents' Experiences of Caring for their Children With Congenital Adrenal Hyperplasia.

Objective: This study investigates various kinds of knowing that European parents use when caring for their children with congenital adrenal hyperplasia (CAH). Methods: Semi-structured qualitative interviews with 20 parents of 22 children with CAH. Results: Parents emphasized the importance of knowing what CAH is and what support their child needs, but also knowing how to cope and make sense of the new situation, how to attend to their child's medical needs as well as how to talk to their child. Parents also reported challenges related to connecting with their social network, experiences of emergency care, and how to help their children become independent. These challenges require knowing now : being able to respond appropriately to unique circumstances. Conclusions: Parents experience diverse challenges that may moderate the effects of the diagnosis on children's well-being. Parenting children with CAH requires the development of knowing that goes beyond medical information.

"It's Part of Me, Not All of Me": Young Women's Experiences of Receiving a Diagnosis Related to Diverse Sex Development.

STUDY OBJECTIVE: To understand young women's experiences of receiving a diagnosis related to diverse sex development. DESIGN: A qualitative narrative analysis of interviews. SETTING: Karolinska University Hospital. PARTICIPANTS: Nine women (aged 20-26 years) with complete androgen insensitivity syndrome, XY or XX gonadal dysgenesis. INTERVENTIONS: Semistructured interviews. MAIN OUTCOME MEASURES: A narrative approach was used to analyze the interviews. This involved identification of individual narratives of receiving the diagnosis, as well as identification of key issues that were common across interviews. RESULTS: The analysis showed how participants' prediagnosis life experiences framed how medical information was perceived upon diagnosis. All participants had been informed about their condition before the study, but not all remembered the name of their diagnosis. Participants described positive characteristics of health professionals, such as being flexible and able to adapt to patients' individual needs. Clinicians' strategies, such as normalizing patients' experiences, were usually perceived as supportive, but were not always considered helpful. After the diagnosis, participants were worried about potential social, practical, and philosophical issues. CONCLUSION: This research highlighted the importance of clinicians taking an exploratory and individualized approach to the sensitive process of disclosing a diagnosis related to diverse sex development to young adults. There are various strategies health professionals can use that might help young people to develop their knowledge about their condition: (1) repeating information to help the patient remember; (2) using language that is not too medicalized; and (3) communicating in a way that is meaningfully connected to patients' everyday lives.