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Journal: International review of psychiatry (Abingdon, England)

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Gender dysphoria (GD) in childhood is a complex phenomenon characterized by clinically significant distress due to the incongruence between assigned gender at birth and experienced gender. The clinical presentation of children who present with gender identity issues can be highly variable; the psychosexual development and future psychosexual outcome can be unclear, and consensus about the best clinical practice is currently under debate. In this paper a clinical picture is provided of children who are referred to gender identity clinics. The clinical criteria are described including what is known about the prevalence of childhood GD. In addition, an overview is presented of the literature on the psychological functioning of children with GD, the current knowledge on the psychosexual development and factors associated with the persistence of GD, and explanatory models for psychopathology in children with GD together with other co-existing problems that are characteristic for children referred for their gender. In light of this, currently used treatment and counselling approaches are summarized and discussed, including the integration of the literature detailed above.

Concepts: Psychology, Gender, Developmental psychology, Knowledge, Gender identity, Transgender, Homosexuality, Gender identity disorder

25

Many studies, reviews, and meta-analyses have reported elevated mental health problems for sexual minority (SM) individuals. This systematic review provides an update by including numerous recent studies, and explores whether SM individuals are at increased risk across selected mental health problems as per dimensions of sexual orientation (SO), genders, life-stages, geographic regions, and in higher quality studies. A systematic search in PubMed produced 199 studies appropriate for review. A clear majority of studies reported elevated risks for depression, anxiety, suicide attempts or suicides, and substance-related problems for SM men and women, as adolescents or adults from many geographic regions, and with varied SO dimensions (behaviour, attraction, identity), especially in more recent and higher quality studies. One notable exception is alcohol-related problems, where many studies reported zero or reversed effects, especially for SM men. All SM subgroups were at increased risk, but bisexual individuals were at highest risk in the majority of studies. Other subgroup and gender differences are more complex and are discussed. The review supports the long-standing mental health risk proposition for SM individuals, overall and as subgroups.

Concepts: Gender, Gender role, Mental disorder, Gender identity, Sexual orientation, Minority, Transgender, Suicide

24

Lesbian, gay, and bisexual (LGB) young people experience a variety of developmental trajectories that consist of milestones, the sequence and timing of which differ across individuals. They include early feelings of being different from peers, the onset of same-sex attraction, questioning one’s sexuality, first same-sex sexual experience, recognition and self-labelling, disclosure to others, first romantic relationship, and self-acceptance. The invention of ‘gay youth’ during the 1970s and 1980s is briefly reviewed with an emphasis on the ways in which the portrait created by early research fails to capture the developmental trajectories of millennial young people. Although some young people struggle with mental health problems as they navigate these milestones, research documents the complexity, variety, and normative nature of the vast majority of LGB young people. A growing chorus of developmental, behavioural, and social scientists now emphasize that many contemporary young people forego sexual confusion, recognize the sex or gender to which they are attracted to and love, and believe they are as mentally healthy as heterosexual young people.

Concepts: LGBT, Sexual orientation, Transgender, Homosexuality, Bisexuality, Gay, Heterosexuality, Lesbian

15

Serotonin (5-hydroxytryptamine, 5-HT)2A receptor agonists have recently emerged as promising new treatment options for a variety of disorders. The recent success of these agonists, also known as psychedelics, like psilocybin for the treatment of anxiety, depression, obsessive-compulsive disorder (OCD), and addiction, has ushered in a renaissance in the way these compounds are perceived in the medical community and populace at large. One emerging therapeutic area that holds significant promise is their use as anti-inflammatory agents. Activation of 5-HT2A receptors produces potent anti-inflammatory effects in animal models of human inflammatory disorders at sub-behavioural levels. This review discusses the role of the 5-HT2A receptor in the inflammatory response, as well as highlight studies using the 5-HT2A agonist ®-2,5-dimethoxy-4-iodoamphetamine [®-DOI] to treat inflammation in cellular and animal models. It also examines potential mechanisms by which 5-HT2A agonists produce their therapeutic effects. Overall, psychedelics regulate inflammatory pathways via novel mechanisms, and may represent a new and exciting treatment strategy for several inflammatory disorders.

10

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Concepts: Gender, Sociology, Gender role, Mental disorder, Schizophrenia, Gender identity, Psychiatry, Transgender

9

The current review gives an overview of brain studies in transgender people. First, we describe studies into the aetiology of feelings of gender incongruence, primarily addressing the sexual differentiation hypothesis: does the brain of transgender individuals resemble that of their natal sex, or that of their experienced gender? Findings from neuroimaging studies focusing on brain structure suggest that the brain phenotypes of trans women (MtF) and trans men (FtM) differ in various ways from control men and women with feminine, masculine, demasculinized and defeminized features. The brain phenotypes of people with feelings of gender incongruence may help us to figure out whether sex differentiation of the brain is atypical in these individuals, and shed light on gender identity development. Task-related imaging studies may show whether brain activation and task performance in transgender people is sex-atypical. Second, we review studies that evaluate the effects of cross-sex hormone treatment on the brain. This type of research provides knowledge on how changes in sex hormone levels may affect brain structure and function.

Concepts: Gender, Gender role, Woman, Gender identity, Transgender, Man, Third gender, Gender studies

7

Medical students' wellbeing and mental health are of extreme importance. Studies from around the world have shown that the rates of burnout appear to be high. It is also well recognized that individuals with mental illnesses frequently avoid seeking help for fear of stigma, affecting their careers and being rejected or treated differently by their peers, or due to the perception that they will be deemed unfit for practice or rejected from their preferred specialty. Students who are open about their mental health conditions are often ostracized by their own peers and dismissed or even mistreated by teachers who consider mental ‘toughness’ to be a requirement for success in the medical arena. The impact of socioeconomic conditions cannot be under-estimated. We carried out a survey of mental health and wellbeing of medical students in the National University of Asuncion. A sample of 180 students across different years showed that 21% had sought help and 4% had been diagnosed with a mental condition before entering medical school; 3% had been previously diagnosed with Attention Deficit Hyperactivity Disorder or Autism Spectrum Disorders; 14% currently consult with a health professional specifically about their mental health; and 8% reported currently taking medication for their mental health. The most common medication was Escitalopram at 21%, followed by Sertraline with 11%. Various sources of stress were identified, all of which were noted to be concerning four specific domains: financial difficulties, familial issues, housing issues, and difficulties surrounding studies. Of these students, 20% were CAGE positive and 9.4% reported using substances to feel better. These findings indicate that medical students need better support to ensure that they function better. They require in-depth exploration of the potential causes of their illnesses.

7

Some people have a gender which is neither male nor female and may identify as both male and female at one time, as different genders at different times, as no gender at all, or dispute the very idea of only two genders. The umbrella terms for such genders are ‘genderqueer’ or ‘non-binary’ genders. Such gender identities outside of the binary of female and male are increasingly being recognized in legal, medical and psychological systems and diagnostic classifications in line with the emerging presence and advocacy of these groups of people. Population-based studies show a small percentage - but a sizable proportion in terms of raw numbers - of people who identify as non-binary. While such genders have been extant historically and globally, they remain marginalized, and as such - while not being disorders or pathological in themselves - people with such genders remain at risk of victimization and of minority or marginalization stress as a result of discrimination. This paper therefore reviews the limited literature on this field and considers ways in which (mental) health professionals may assist the people with genderqueer and non-binary gender identities and/or expressions they may see in their practice. Treatment options and associated risks are discussed.

Concepts: Male, Female, Gender, Sex, Gender identity, Man, Masculinity, Third gender

3

The current literature shows growing evidence of a link between gender dysphoria (GD) and autism spectrum disorder (ASD). This study reviews the available clinical and empirical data. A systematic search of the literature was conducted using the following databases: PubMed, Web of Science, PsycINFO and Scopus; utilizing different combinations of the following search terms: autism, autism spectrum disorder (ASD), Asperger’s disorder (AD), co-morbidity, gender dysphoria (GD), gender identity disorder (GID), transgenderism and transsexualism. In total, 25 articles and reports were selected and discussed. Information was grouped by found co-occurrence rates, underlying hypotheses and implications for diagnosis and treatment. GD and ASD were found to co-occur frequently - sometimes characterized by atypical presentation of GD, which makes a correct diagnosis and determination of treatment options for GD difficult. Despite these challenges there are several case reports describing gender affirming treatment of co-occurring GD in adolescents and adults with ASD. Various underlying hypotheses for the link between GD and ASD were suggested, but almost all of them lack evidence.

Concepts: Gender, Autism, Pervasive developmental disorder, Asperger syndrome, Autism spectrum, Gender identity, Transgender, Gender identity disorder

2

The continuation of lithium while breastfeeding is a controversial topic, and clinical recommendations vary. A systematic review was completed of available data on lithium and breastfeeding to determine the degree of lithium exposure through breast milk and assess the potential risk to the infant. Databases, including PubMed MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane CENTRAL Register of Controlled Trials databases, were searched for articles on lithium and breastfeeding from the start dates of the databases through December 2018. Articles were included if the report included at least one maternal serum/plasma and/or breast milk lithium concentration and one infant serum/plasma lithium concentration. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Twelve articles, all case reports, were selected for inclusion out of 441 articles that were found and 230 that were reviewed from the search. Data are limited on the safety of lithium continuation while breastfeeding. Among the adverse effects reported, it is difficult to differentiate poor outcomes from factors affecting infant health, concomitant medications, and gestational lithium exposure. Recommendations on whether to continue lithium while breastfeeding must be personalized to the individual woman and her infant.