"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).

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.

Self-Reported Changes in Attractions and Social Determinants of Mental Health in Transgender Adults.

This study examined associations between changes in self-reported attractions and mental health in a community-based sample of self-identified transgender adults. Participants were purposively recruited in 2013 using bimodal sampling methods and completed a one-time survey. Multivariable logistic regression models estimated adjusted risk ratios and 95 % confidence intervals to examine associations between changes in attractions and mental health outcomes (lifetime self-harm, suicide attempts, depression diagnosis; past-week clinically significant depressive distress assessed via CES-D 10) among the entire sample (N = 452; 285 female-to-male spectrum, 167 male-to-female spectrum) and after gender transition among those who had socially transitioned (n = 205; 156 female-to-male spectrum, 49 male-to-female spectrum). Models were adjusted for known population social determinants (age, race/ethnicity, gender identity, socioeconomic status, sexual orientation identity), transgender-specific determinants (age of transgender realization, social transition, medical transition, visual gender nonconformity, non-binary gender identification), and survey mode (online vs. in-person sampling). Lifetime changes in attractions were significantly associated with increased probability of all mental health outcomes; individuals reporting any change in attractions were more likely than individuals not reporting changes to indicate lifetime self-harm, suicide attempts, depression diagnosis, and current depressive distress (all ps < .05). Changes in attractions post-social transition were not significantly associated with mental health outcomes. Many, but not all, population and transgender-specific social determinants were significantly associated with mental health in the full sample and among those who had socially transitioned. Clinical implications of findings about changes in attractions and mental health are discussed for transgender individuals.

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

Trans individuals' facilitative coping: An analysis of internal and external processes.

Existing research on trans individuals has primarily focused on their negative experiences and has disproportionately examined coming-out processes and identity development stages. Using a grounded theory approach, this qualitative study sought to examine facilitative coping processes among trans-identified individuals. Facilitative coping was operationalized as processes whereby individuals seek social support, learn new skills, change behaviors to positively adapt, and find alternative means to seek personal growth and acceptance. The sample included 15 participants who self-identified with a gender identity that was different from their assigned sex at birth. Results yielded a total of nine overarching themes: Accepting Support from Others, Actions to Increase Protection, Active Engagement Throughout the Transition Process, Actively Seeking Social Interactions, Engaging in Exploration, Internal Processes Leading to Self-Acceptance, Self-Efficacy, Shifts Leading to Embracing Change and Flexibility, and Utilization of Agency. Based on the analysis, a theoretical model emerged that highlighted the importance of internal and external coping processes in facilitating gender identity development and navigating stressors among trans individuals. Clinical implications focusing on how to implement facilitative coping processes are discussed. (PsycINFO Database Record

Imagining the future: Perspectives among youth and caregivers in the trans youth family study.

Future perspectives of transgender youth and their caregivers may be shaped by knowledge of discrimination and adverse mental health among transgender adults. Qualitative data from the Trans Youth Family Study were analyzed to examine how transgender and gender nonconforming (TGN) youth and their caregivers imagine the youth's future. A community-based sample of 16 families (16 TGN youth, ages 7-18 years, and 29 caregivers) was recruited from 2 regions in the United States. Participants completed in-person qualitative interviews and surveys. Interview transcripts were analyzed using grounded theory methodology for coding procedures. Analyses yielded 104 higher order themes across 45 interviews, with 8 prominent themes: comparing experiences with others, gender affirming hormones, gender affirming surgery, gender norms, questioning whether the youth is really transgender, expectations for romantic relationships, uncertainty about the future, and worries about physical and emotional safety. A conceptual model of future perspectives in TGN youth and caregivers is presented and clinical implications are discussed. (PsycINFO Database Record

Transgender community belongingness as a mediator between strength of transgender identity and well-being.

This study examined transgender community belongingness as a mediator between strength of transgender identity and well-being. A total of 571 transgender adults (n = 209 transgender women, n = 217 transgender men, and n = 145 nonbinary-identified individuals) completed an online survey assessing transgender community belongingness, strength of transgender identity (operationalized as the extent to which a person self-categorizes their identity as transgender and the extent to which they believe their gender transition to be important to their self-definition), and well-being (using measures of self-esteem, satisfaction with life, and psychological well-being). Structural equation modeling was used to analyze the data. When controlling for participants' income, age, and stage of gender transition, transgender community belongingness fully mediated the relationship between strength of transgender identity and well-being. Strength of transgender identity was indirectly and positively related to well-being through community belongingness, but was not directly related to well-being. Results suggest that transgender community belongingness is an important construct in the mental health of transgender people. The strength of a person's transgender identity also appears to be a significant construct in transgender people's well-being via its relationship with transgender community belongingness. Implications of the findings are discussed. (PsycINFO Database Record

Good-enough level and dose-effect models: Variation among outcomes and therapists.

OBJECTIVE: The current study examined the good-enough level (GEL) and dose-effect model on three outcome variables: well-being, symptom distress, and life functioning, while accounting for therapist effects. The dose-effect model assumes the rate of change is consistent across clients, and the GEL model assumes that the rate of change will vary according to the total length of treatment. METHOD: The sample included 13,664 clients who completed 2-100 sessions of therapy. RESULTS: The GEL model was a better fit to the data compared to the dose-effect model for all outcomes. There were fewer changes in life functioning compared to well-being and symptom distress for clients. There were significant therapist effects for changes in symptom distress and life functioning, but not for the rates of change in well-being. CONCLUSION: Therapists should consider the rates of change for their own clients as well as by outcome.

Sexual minority women's experiences of sexual pressure: a qualitative investigation of recipients' and initiators' reports.

Sexual pressure can have detrimental effects to individuals both physically and emotionally; however, research in this area is lacking regarding the experiences by lesbian, gay, bisexual, queer, and questioning (LGBQ) women. This online study qualitatively examined sexual pressure experienced and explained by LGBQ women (n = 50) using grounded theory methodology. Participants responded to open-ended questions by providing perspectives from both those who were on the receiving end of the sexual pressure (recipients) and from those who pressured their partners (initiators). Results indicated that there were eight overarching themes, 43 higher order categories, and 241 line-by-line codes. The eight overarching themes included: Reasons to Not Want Sex, Reasons for Pressuring, Reasons for Giving In, Actions of Initiators, Expectations, Communication, Negative Outcomes, and Positive Reactions. Negative Outcomes was the most common theme endorsed. Several higher order categories indicated the unique experiences of sexual minority women, namely trying to be "normal" (e.g., engaging in sexual acts as a result of internalized homophobia), experiencing more pressure from men, and self-consciousness (specifically related to lack of knowledge about sex with women). Implications for the current study include the importance of addressing sexual pressure with sexual minority women and creating interventions, such as assertiveness training and communication skills, that could assist both recipients and initiators with engaging in mutually satisfactory sexual practices.

Trajectories of Change in Psychotherapy.

OBJECTIVE: The current study used multilevel growth mixture modeling to ascertain groups of patients who had similar trajectories in their psychological functioning over the course of short-term treatment. METHOD: A total of 10,854 clients completed a measure of psychological functioning before each session. Psychological functioning was measured by the Behavioral Health Measure, which is an index of well-being, symptoms, and life-functioning. Clients who attended 5 to 25 sessions at 46 different university/college counseling centers and one community mental health center were included in this study. Client diagnoses and the specific treatment approaches were not known. RESULTS: A 3-class solution was a good fit to the data. Clients in classes 1 and 3 had moderate severity in their initial psychological functioning scores, and clients in class 2 had more distressed psychological functioning scores. The trajectory for clients in class 1 was typified by early initial change, followed by a plateau, and then another gain in psychological functioning later in treatment. The trajectory for clients in class 2 demonstrated an initial decrease in functioning, followed by a rapid increase, and then a plateau. Last, the clients in class 3 had a steady increase of psychological functioning, in a more linear manner. CONCLUSION: The trajectories of change for clients are diverse, and they can ebb and flow more than traditional dose-effect and good-enough level models may suggest.

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.

The Development and Pilot Testing of a Minority Stress Psychoeducation Tool for Transgender and Nonbinary People.

Purpose: In this study, we aimed to develop and test the acceptability of a minority stress psychoeducation tool for transgender and nonbinary (TNB) people. Methods: Patients in one treatment group who were enrolled in a larger randomized controlled trial received this study's minority stress psychoeducation pre-treatment. Data on the acceptability of the tool and minority stress experiences were collected post-treatment. Results: All (100%) patients reported that the psychoeducation tool was helpful and qualitative data suggested patients experienced an increased ability to externalize minority stress experiences. Conclusion: Results support the acceptability of this minority stress psychoeducation tool for TNB patients. Clinical trial number: NCT03369054.

Psychological Assessment for Gender-Affirming Care in Transgender and Nonbinary Youth: The Companionship Model.

ABSTRACT: This article introduces The Companionship Model as a template for conducting ethical and affirming assessment sessions for transgender and nonbinary youths (TNBY) and their guardians. The Companionship Model emphasizes proactive clinical companionship as TNBY and their guardians navigate access to gender-affirming care. The model offers specific action steps for establishing a therapeutic alliance and centers TNBY and their guardians' access to resources based on the informed consent/assent process. In this article, we provide sample session questions and illustrative clinical examples.

Longitudinal Family Functioning and Mental Health in Transgender and Nonbinary Youth and Their Families.

This study examined concordance of family members' perspectives of family functioning and mental health across two years in families with transgender and/or nonbinary youth (TNBY). Participants were 89 family members (30 TNBY, age 13-17 years; 44 cisgender caregivers; 15 cisgender siblings, age 14-24 years) from 30 families from the U.S. New England region. Family members completed an online survey every 6-8 months for 5 waves between December 2015 and Feb 2019. Surveys assessed family functioning (quality of communication, satisfaction with family) and the following mental health-related outcomes: depression and anxiety symptoms, non-suicidal self-injury, suicidality, self-esteem, and resilience. Analyses tested concordance of family functioning and mental health across family members. Reports of family functioning changed over time, and family members were not consistently concordant in their reports of family functioning. Caregivers perceived a higher quality family communication than TNBY at all waves and higher than siblings at some waves. Perceptions of family satisfaction did not show a clear pattern between family member types across waves. The greatest concordance of perceived family functioning was between caregivers and siblings and between TNBY and siblings. Across all waves, TNBY reported more severe depression and anxiety symptoms than their caregivers and siblings, and more non-suicidal self-injury than their siblings. Compared to siblings, TNBY reported higher self-esteem, but less resilience. This study highlights opportunities for intervention in clinical work with TNBY and their families. Providers working with families with TNBY should use family systems approaches to support the mental health of all family members.

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.

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.