Informed Consent or Scare Tactics? A Response to Levine et al.'s "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults".

This responds to "Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults" by Levine et al., part of a small but growing, critical response to contemporary treatments of gender dysphoric/incongruent (GD/GI) children and adolescents. This author, while disagreeing with Levine et al. and other critics, hopes that with dialogue, research and engagement with the wider world, needs of all children, adolescents and young adults-those who have GD/GI and those who may not-will be best served. Critics of gender affirming treatments cite growing numbers of cases, "low level of evidence" supporting treatment, irreversible side effects and expressing regrets as reasons to oppose gender affirmative treatments. Although sharing similar concerns, the author does not conclude treatments should not be offered when appropriate. The critics' alternative reads as "just talk to the young people and find out what is really bothering them." Lacking empirical evidence for that approach does not appear to trouble them.Levine et al.'s caricature of informed consent, which this author parodies, would dissuade anyone from treatment. Their approach does not appear to be written for purposes of engaging frontline clinicians with the aim of improving treatment. Instead, they read as appeals to third parties unfamiliar with the clinical presentations of these children-parents, caretakers courts, legislatures, state health departments and national health care systems-to discourage treatments from proceeding. This impression is further buttressed by a declaration of financial support from The Society for Empirical-Based Gender Medicine, a small group of outliers from mainstream clinicians treating minors with GD/GI who present as "truth-speaking" experts regarding "facts" being ignored, elided over or perhaps even covered up by the mainstream.The author concludes by noting that clinicians who advocate for delaying treatment to GD/GI minors who need and may benefit from it to "protect" those who "aren't really" transgender is an ethically troubling issue. In other words, "first, do no harm" is a sword that cuts two ways.

Counselling and psychotherapy service use in Chinese sexual minority populations: a nationwide survey.

BACKGROUND: This study investigated the prevalence and factors associated with counselling and psychotherapy service use among Chinese sexual minority populations. METHODS: A nationwide cross-sectional study was performed using snowball sampling method, which led to the inclusion of 18,193 participants. Participants' sociodemographic background, clinical, and psychological data were gathered. Multivariate logistic regression analysis was performed to explore any associated factors. RESULTS: There were 2007 participants who had used counselling and psychotherapy service out of the total population. Among those who had used psychotherapy services, 80.2% participants perceived discrimination, 1.1% reported that they had been refused treatment by a counsellor and/or psychotherapist, 1.6% had experienced verbal harassment, and 8.4% reported that their counsellor and/or psychotherapist lacked knowledge and experience in treating sexual minorities. In addition, regression analyses indicated that those who were divorced/widowed, had religious beliefs, and those who had experienced discrimination, verbal harassment, and rejection for treatment by health professionals all had an increased likelihood of utilising counselling and psychotherapy service. CONCLUSIONS: Service providers and policy makers in China should improve the quality and availability of counselling and psychotherapy services to address the mental health needs of sexual minority populations.

A Qualitative Investigation Into Faith and LGBTQ Identities in a Nonclinical Sample of Readers of the Dear Abby Column: The Dear Abby Project.

ABSTRACT: To better understand the relationship between faith and LGBTQ+ identity, we conducted a qualitative analysis of 86 respondents to a general question posed through the Dear Abby column. Responses were anonymized and analyzed using a grounded theory approach. Analysis revealed six themes, reflecting a diversity of lived experience from community rejection to acceptance, and self-rejection to feelings of acceptance by God. Despite frequent media portrayals of conflict between faith and LGBTQ+ identity, the reality is more complex, and faith and LGBTQ+ identity development can be complementary.

Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD.

The American Psychiatric Association (APA) recently completed a several year process of revising the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). During that time, there were objections raised to retaining DSM's gender identity disorder diagnoses and calls to remove them, just as homosexuality had been removed from DSM-II in 1973. At the conclusion of the DSM-5 revision process, the gender diagnoses were retained, albeit in altered form and bearing the new name of 'gender dysphoria'. The author of this paper was a member of the DSM-5 Workgroup on Sexual and Gender Identity Disorders and presently serves on the WHO Working Group on Sexual Disorders and Sexual Health. Both groups faced similar tasks: reconciling patients' needs for access to care with the stigma of being given a psychiatric diagnosis. The differing nature of the two diagnostic manuals led to two different outcomes. As background, this paper updates the history of homosexuality and the gender diagnoses in the DSM and in the International Statistical Classification of Diseases and Related Health Problems (ICD) as well as what is expected to happen to the homosexuality and gender diagnoses following the current ICD-11 revision process.

New Italian lesbian, gay and bisexual psychotherapy guidelines: A review.

Although homosexuality was depathologized in the last century and the majority of mental health professionals consider it to be a normal variant of human sexuality, some psychologists and psychiatrists still have negative attitudes toward lesbian, gay and bisexual (LGB) clients. Sometimes they provide interventions aimed at changing sexual orientation through 'reparative' or 'conversion' therapies. At other times their interventions are influenced by anti-gay prejudices or simply by lack of knowledge about sexual minorities. This paper argues for the need for appropriate treatment guidelines aimed at providing bias-free, respectful, and effective interventions given that Italian health associations have delayed providing them. Some of the main guidelines recently approved by the Consiglio Nazionale dell'Ordine degli Psicologi (National Council of the Italian Association of Psychologists) are presented. Issues addressed include differences between gender and sexual orientation, minority stress, including perceived stigma and internalized stigma, homophobic bullying, coming out, and resilience. Respectful listening to LGB and questioning clients, affirming their identities and fostering a sense of resilience are essential requirements for all mental health professionals wishing to provide effective interventions in a society where sexual minorities are subjected to discrimination throughout their entire life cycle.

Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11).

The World Health Organization is developing the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), planned for publication in 2017. The Working Group on the Classification of Sexual Disorders and Sexual Health was charged with reviewing and making recommendations on disease categories related to sexuality in the chapter on mental and behavioural disorders in the 10th revision (ICD-10), published in 1990. This chapter includes categories for diagnoses based primarily on sexual orientation even though ICD-10 states that sexual orientation alone is not a disorder. This article reviews the scientific evidence and clinical rationale for continuing to include these categories in the ICD. A review of the evidence published since 1990 found little scientific interest in these categories. In addition, the Working Group found no evidence that they are clinically useful: they neither contribute to health service delivery or treatment selection nor provide essential information for public health surveillance. Moreover, use of these categories may create unnecessary harm by delaying accurate diagnosis and treatment. The Working Group recommends that these categories be deleted entirely from ICD-11. Health concerns related to sexual orientation can be better addressed using other ICD categories.

L'Organisation mondiale de la Santé est en train de mettre au point la 11e révision de la Classification statistique internationale des maladies et des problèmes de santé connexes (CIM-11), dont la publication est prévue pour 2017. Le Groupe de travail sur la Classification des troubles sexuels et de la santé sexuelle a été chargé d'examiner et de faire des recommandations sur les catégories de maladies liées à la sexualité dans le chapitre sur les troubles mentaux et comportementaux de la 10e révision (CIM-10) qui a été publiée en 1990. Ce chapitre comprend les catégories des diagnostics basés principalement sur l'orientation sexuelle même si la CIM-10 stipule que l'orientation sexuelle seule n'est pas un trouble. Cet article examine les données scientifiques et les raisons cliniques pour continuer à inclure ces catégories dans la CIM. Un examen des données publiées depuis 1990 a révélé le peu d'intérêt scientifique pour ces catégories. En outre, le Groupe de travail n'a trouvé aucune preuve de leur utilité clinique: elles ne contribuent pas à la fourniture des services de soins ou à la sélection du traitement, et elles ne fournissent aucune information essentielle en matière de surveillance de la santé publique. Par ailleurs, l'utilisation de ces catégories peut créer des dommages inutiles en retardant le diagnostic précis et le traitement. Le Groupe de travail recommande que ces catégories soient entièrement supprimées de la CIM-11. Les problèmes de santé liés à l'orientation sexuelle peuvent être mieux traités en utilisant les autres catégories de la CIM.

La Organización Mundial de la Salud está desarrollando la undécima revisión de la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud (CIE-11), cuya publicación está planeada para el 2017. El Grupo de Trabajo sobre la Clasificación de Trastornos Sexuales y Salud Sexual fue encargado de revisar y hacer recomendaciones sobre estas categorías de enfermedades relacionadas con la sexualidad en el capítulo sobre trastornos mentales y del comportamiento en la décima revisión (CIE-10), publicada en 1990. Este capítulo incluye categorías para diagnósticos basadas principalmente en la orientación sexual, a pesar de que la CIE-10 afirma que la orientación sexual en sí misma no es un trastorno. Este artículo revisa las pruebas científicas y los fundamentos clínicos para continuar incluyendo estas categorías en la CIE. Una revisión de las pruebas publicada desde 1990 encontró poco interés científico en estas categorías. Asimismo, el Grupo de Trabajo no encontró pruebas de que fueran útiles clínicamente: no contribuyen a la prestación de servicios sanitarios ni a la selección de tratamientos. Tampoco proporcionan información esencial para la vigilancia de la salud pública. Además, el empleo de estas categorías podría ocasionar un daño innecesario al retrasar los diagnósticos precisos y el tratamiento. El Grupo de Trabajo recomienda que se eliminen totalmente estas categorías de la CIE-11. Los problemas de salud relacionados con la orientación sexual se pueden abordar mejor utilizando otras categorías de la CIE.

Ethical issues raised by the treatment of gender-variant prepubescent children.

Transgender issues and transgender rights have become increasingly a matter of media attention and public policy debates. Reflecting changes in psychiatric perspectives, the diagnosis of "trans-sexualism" first appeared in the International Statistical Classification of Diseases and Related Health Problems in 1975 and shortly thereafter, in 1980, in the Diagnostic and Statistical Manual of Mental Disorders. Since that time, international standards of care have been developed, and today those standards are followed by clinicians across diverse cultures. In many instances, treatment of older adolescents and adults is covered by national health care systems and, in some cases, by private health insurance. Most recently, the Medicare ban on coverage for gender reassignment surgery was lifted in 2014. In contrast to the relative lack of controversy about treating adolescents and adults, there is no expert clinical consensus regarding the treatment of prepubescent children who meet diagnostic criteria for what was referred to in both DSM-IV-TR and ICD-10 as gender identity disorder in children and now in DSM-5 as gender dysphoria. One reason for the differing attitudes has to do with the pervasive nature of gender dysphoria in older adolescents and adults: it rarely desists, and so the treatment of choice is gender or sex reassignment. On the subject of treating children, however, as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood. Further, most of the boys' gender dysphoria desisted, and in adulthood, they identified as gay rather than as transgender. In an effort to clarify best treatment practices for transgender individuals, a recent American Psychiatric Association Task Force on the Treatment of Gender Identity outlined three differing approaches to treating prepubescent gender dysphoric children.

Minding the body: situating gender identity diagnoses in the ICD-11.

The World Health Organization (WHO) is in the process of revising the International Statistical Classification of Diseases and Related Health Problems (ICD) and ICD-11 has an anticipated publication date of 2015. The Working Group on the Classification of Sexual Disorders and Sexual Health (WGSDSH) is charged with evaluating clinical and research data to inform the revision of diagnostic categories related to sexuality and gender identity that are currently included in the mental and behavioural disorders chapter of ICD-10, and making initial recommendations regarding whether and how these categories should be represented in the ICD-11. The diagnostic classification of disorders related to (trans)gender identity is an area long characterized by lack of knowledge, misconceptions and controversy. The placement of these categories has shifted over time within both the ICD and the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), reflecting developing views about what to call these diagnoses, what they mean and where to place them. This article reviews several controversies generated by gender identity diagnoses in recent years. In both the ICD-11 and DSM-5 development processes, one challenge has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to healthcare. In this connection, this article discusses several human rights issues related to gender identity diagnoses, and explores the question of whether affected populations are best served by placement of these categories within the mental disorders section of the classification. The combined stigmatization of being transgender and of having a mental disorder diagnosis creates a doubly burdensome situation for this group, which may contribute adversely to health status and to the attainment and enjoyment of human rights. The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services.

Is it really about freedom of thought?

This opinion piece responds to Marcus Evans's 'Freedom to Think' regarding treating adolescents diagnosed with gender dysphoria (DSM)/gender incongruence (ICD). Evans notes not everything is known about GD/GI, particularly its 'causes'. Although correct, he presents this fact as a rationale for delaying treatment for all children presenting with GD/GI symptoms. However, Marcus does not specify how long such prolonged evaluations should last nor does he have much of an evidence base to support his recommendation. This author believes delaying treatment for GD/GI adolescents who need it for the benefit of children who 'aren't really' transgender is an ethically troubling issue.

There is no there there: a discussion of "Narcissism and self-esteem among homosexual and heterosexual male students".

"Narcissism and Self-Esteem among Homosexual and Heterosexual Male Students," states as its aim: Acknowledging the changes both homosexuality and narcissism went through, the present study aims at empirically reviving the discussion about the association between these two phenomena. Based on the Freudian assumption that homosexual individuals develop on a narcissistic basis and look for a young man who resembles themselves, the hypothesis of this study predicts that their level of narcissism would be higher and level of self-esteem would be lower compared to their heterosexual counterparts. (Rubinstein, this issue).

Queer diagnoses: parallels and contrasts in the history of homosexuality, gender variance, and the diagnostic and statistical manual.

The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental disorder and that perpetuating DSM-IV-TR's GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.

Queer Diagnoses Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual (DSM) Review and Recommendations Prepared for the DSM-V Sexual and Gender Identity Disorders Work Group.

(Copyright © 2009, American Psychiatric Association. Published with permission).

Issues Arising in Psychotherapy With Lesbian, Gay, Bisexual, and Transgender Patients.

In many ways, psychotherapy with lesbian, gay, bisexual, and transgender (LGBT) patients does not differ from psychotherapy for heterosexual, gender conforming, and cisgender patients. Additionally, concepts and considerations that arise in psychotherapy with LGBT patients can parallel issues that arise in psychotherapy with patients of other stigmatized minority groups. In this article, the authors discuss the concept of minority stress and its relationship with mental health conditions and review specific issues that may arise with this heterogeneous patient population, including being in the closet, coming out of the closet, the psychotherapeutic search for "causes" of sexual orientation and gender identity, and therapist self-disclosure.

The victim-bully cycle of sexual minority school adolescents in China: prevalence and the association of mood problems and coping strategies.

AIMS: Compared to their heterosexual peers, youth who identify as lesbian, gay or bisexual (LGB) tend to suffer higher rates of peer victimisation from bullying. However, studies of LGB adolescents' participation as bullies are scarce. We aimed to examine the possible association of sexual minority identity and the heightened risk of not only being bullied but bullying others as well. We also explored the effect of one's sexual identity on their involvement in bullying through the mediation of coping strategies and mood states. METHODS: A total of 12 218 students were recruited from 18 secondary schools in China. The demographic information, positive and negative coping strategies, mood state (anxiety, depression and hypomania) and information related to bullying and being bullied were collected. Multinomial regression was used to assess the heightened risk of sexual minority groups in comparison to their heterosexual adolescents' counterparts. A structural equation model (SEM) was used to test the mediating role of coping strategy and mood state between one's sex, sexual identity and bullying experience. RESULTS: Two trends could be observed: (1) LGB groups reported heightened risks of being bullied and bullying others at school than heterosexual peers. However, being a sexual-undeveloped girl seemed to have a protective effect on bullying-related problems. (2) Birth-assigned males were more likely to be bullied as well as bullying others at school when compared to birth-assigned females. SEM analysis revealed that being a sexual minority was directly associated with a higher frequency of being bullied (B = 0.16, 95% CI [0.10, 0.22], p < 0.001) but not bullying others (B = 0.02, 95% CI [-0.02, 0.06], p = 0.398) when compared to the heterosexual group. Negative coping, hypomania, anxiety and depression were associated with a higher frequency of being bullied, while positive coping was associated with a lower frequency of being bullied. Moreover, negative coping, hypomania and depression were associated with a higher frequency of bullying others, while positive coping was associated with a reduced likelihood of bullying others. In addition, being bullied and bullying others were significantly correlated in the SEM model. CONCLUSIONS: This novel research investigated the dynamic nature of the interaction between victim and bullying of LGB school adolescents in China, with a specific exploration of the psychological mechanism behind the pattern of being bullied and bullying others. School-level interventions aimed at teaching positive coping strategies to lower psychological distress are recommended to support sexual minority students.

Proposed Declassification of Disease Categories Related to Sexual Orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11).

(Reprinted with permission from the Bulletin of the World Health Organization).

Mental Health Status of Cisgender and Gender-Diverse Secondary School Students in China.

Importance: Transgender or gender nonconforming (TGNC) adolescents face a wide range of physical and mental health concerns. However, there has been no school-based study to explore the prevalence and mental health status of these adolescents in mainland China. Objectives: To assess the mental well-being of TGNC adolescents in China by comparing them with their cisgender peers. Design, Setting, and Participants: This was a cross-sectional survey study. Of the 12 354 adolescents who completed the questionnaire, 246 did not specify to which sex they identified and were therefore excluded from further analysis. Therefore, a total of 12 108 adolescents were included from 18 secondary schools in Suzhou city, China, from June 2019 to July 2019. Participants provided consent and answered questions on sex assigned at birth and gender identity. Main Outcomes and Measures: All participants completed questionnaires, including the Patient Health Questionnaire for the measurement of depressive symptoms, a generalized anxiety disorder screening, the Pittsburgh Sleep Quality Index, and a self-harm and suicide risk checklist. The frequency of being bullied at school was also measured. Participants who reported their perceived gender as the opposite of their assigned sex at birth were classified as transgender, those who identified as neither male nor female were classified as nonbinary, and those who were not sure about their perceived gender were classified as questioning. All of these participants were categorized as TGNC adolescents. Results: A total of 12 108 adolescents (mean [SD] age, 15.8 [1.0] years; 6518 [53.8%] assigned male at birth [AMAB]) participated in the study. Of the 6518 participants AMAB in the sample, 5855 (89.8%) were classified as cisgender boys, 208 (3.2%) as transgender girls (transgender youth who perceive their current gender identity to be female), 138 (2.1%) as nonbinary youth AMAB, and 317 (4.9%) as questioning youth AMAB. Of the 5590 participants assigned female at birth (AFAB), 4142 (74.1%) were classified as cisgender girls, 861 (15.4%) as transgender boys (transgender youth who perceive their current gender identity to be male), 112 (2.0%) as nonbinary youth AFAB, and 475 (8.5%) as questioning youth AFAB. Compared with cisgender adolescents, TGNC adolescents reported significantly higher health concerns including lower overall health (t11 872 = -7.36; P < .001), poorer sleep (t11 683 = 10.49; P < .001), higher depression and anxiety symptoms (t11 830 = 12.43 and t11 847 = 11.47, respectively; P < .001), and higher rate of self-harm and suicide ideation (t11 860 = 12.22; P < .001). The TGNC youth who were AMAB were also more likely to be bullied at school than cisgender boys (transgender girls: odds ratio [OR], 2.34 [95% CI, 1.64-3.33]; nonbinary youth AMAB: OR, 1.97 [95% CI, 1.23-3.16]; and questioning youth AMAB: OR, 1.95 [95% CI, 1.43-2.67]). The TGNC groups also reported significantly greater amounts of thoughts of self-harm (transgender girls: OR, 3.06 [95% CI, 2.24-4.19]; transgender boys: OR, 4.06 [95% CI, 3.47-4.74]; nonbinary youth AMAB: OR, 2.86 [95% CI, 1.93-4.23]; nonbinary youth AFAB: OR, 3.71 [95% CI, 2.46-5.59]; questioning youth AMAB: OR, 2.61 [95% CI, 1.98-3.44]; and questioning youth AFAB: OR, 3.35 [95% CI, 2.70-4.16]), thoughts of suicide (transgender girls: OR, 3.93 [95% CI, 2.88-5.38]; transgender boys: OR, 3.71 [95% CI, 3.10-4.21]; nonbinary youth AMAB: OR, 3.13 [95% CI, 2.11-4.63]; nonbinary youth AFAB: OR, 3.78 [95% CI, 2.50-5.71]; questioning youth AMAB: OR, 2.53 [95% CI, 1.93-3.33]; and questioning youth AFAB: OR, 3.94 [95% CI, 3.17-4.88]), suicide plan formation (transgender girls: OR, 4.44 [95% CI, 2.88-6.83]; transgender boys: OR, 2.66 [95% CI, 2.03-3.50]; nonbinary youth AMAB: OR, 5.36 [95% CI, 3.22-8.93]; nonbinary youth AFAB: OR, 4.06 [95% CI, 2.25-7.30]; and questioning youth AFAB: OR, 2.36 [95% CI, 1.63-3.43]), deliberate self-harm during the last month (cisgender girls: OR, 1.49 [95% CI, 1.33-1.68]; transgender girls: OR, 2.74 [95% CI, 1.93-3.91]; transgender boys: OR, 3.06 [95% CI, 2.57-3.66]; nonbinary youth AMAB: OR, 2.56 [95% CI, 1.66-3.94]; nonbinary youth AFAB: OR, 3.06 [95% CI, 1.95-4.81]; questioning youth AMAB: OR, 2.14 [95% CI, 1.56-2.92]; and questioning youth AFAB: OR, 2.53 [95% CI, 2.00-3.01]), and attempts of suicide (transgender girls: OR, 4.35 [95% CI, 2.88-6.56]; transgender boys: OR, 2.92 [95% CI, 2.26-3.76]; nonbinary youth AMAB: OR, 3.94 [95% CI, 2.36-6.55]; nonbinary youth AFAB: OR, 3.06 [95% CI, 1.67-5.63]; questioning youth AMAB: OR, 2.61 [95% CI, 1.73-3.94]; and questioning youth AFAB: OR, 1.93 [95% CI, 1.33-2.81]) compared with cisgender boys. Conclusions and Relevance: Results of this cross-sectional survey study suggest poor mental health status among TGNC adolescents in China; in addition, findings suggest a compelling need for researchers, practitioners, and policy makers to address these mental health problems. Particular school-based interventions are recommended to support the mental health well-being of TGNC adolescents.

Suicidal ideation and attempted suicide amongst Chinese transgender persons: National population study.

BACKGROUND: This study aims to understand suicidal ideation and suicide attempts among transgender individuals through an in-depth analysis of a nation-wide population general survey in China. METHODS: Transgender Men (TM) and Women (TW) were investigated through a cross-sectional survey. A structured questionnaire was used to investigate participants' demographic information, perceived sexuality conflicts, childhood adversity and mental health conditions. Logistic regression models were utilized to investigate risk factors associated with suicidal ideation and suicide attempts in these groups. We also conducted a quasi-meta-analysis in order to compare the prevalence of suicidal ideation and attempted suicide between general and transgender populations in China. RESULTS: A total of 1309 participants across 32 provinces and municipalities in China took part in this survey, out of 2060 valid questionnaires. In this transgender population, the lifetime prevalence of suicidal ideation and an attempt at suicide were 56.4% and 16.1%, respectively. This estimated prevalence rate is far greater than in Chinese community samples. For all transgender people, disliking birth-assigned sex, seeking sex reassignment surgery, having intense conflicts with parents, lifetime history of suffering from major depressive disorder, a recent episode of depression, self-harm, and seeking mental health services were significantly associated with increased risk of suicidal ideation. An education level of high school or equivalent, being married and/or separated/divorced, having intense conflicts with parents, or self-harm and seeking mental health services were all significantly associated with increased risk of suicide attempt. Although most risk factors for TM and TW were equivalent across groups, differences were observed in both suicidal ideation and suicide attempt models. LIMITATIONS: The cross-sectional study design and lack of follow-up data are limitations of this study. CONCLUSIONS: This is the first study to examine suicide within a Chinese transgender population. The clinical implications of these findings for Chinese mental health professionals are discussed. Also, the evidence from this study can be used to inform the practices of suicide prevention workers, and policy makers working with the transgender population.

A history of homosexuality and organized psychoanalysis.

Today the Academy of Psychoanalysis and Dynamic Psychiatry welcomes its gay and lesbian members. Yet at the time of its 1956 founding, organized psychoanalytic attitudes toward homosexuality could be reasonably characterized as hostile. First there was a transition from Freud's early views of homosexuality as immature to later neofreudian theories that pathologized same-sex attractions and behavior. Following the 1973 decision of the American Psychiatric Association to remove homosexuality from the DSM, homosexuality is now more commonly regarded as a normal variant of human sexuality. The history of psychoanalytic attitudes toward homosexuality reinforces the impression that psychoanalytic theories cannot be divorced from the political, cultural, and personal contexts in which they are formulated. This history also shows that analysts can take positions that either facilitate or obstruct tolerance and acceptance.