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The reform of the Common European Asylum System: fifteen recommendations from a sexual orientation and gender identity perspective

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The reform of the Common European Asylum System: fifteen recommendations from a sexual orientation and gender identity perspective

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Queering asylum in Europe: a survey report

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Queering asylum in Europe: a survey report

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An exercise in detachment: the Council of Europe and sexual minority asylum claims

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An exercise in detachment: the Council of Europe and sexual minority asylum claims

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Queering asylum in Europe: legal and social experiences of seeking international protection on grounds of sexual orientation and gender identity

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Queering asylum in Europe: legal and social experiences of seeking international protection on grounds of sexual orientation and gender identity

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Improving SOGI asylum adjudication: putting persecution ahead of identity

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Improving SOGI asylum adjudication: putting persecution ahead of identity

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Legal violence and (in)visible families: how law shapes and erases family life in SOGI asylum in Europe

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Legal violence and (in)visible families: how law shapes and erases family life in SOGI asylum in Europe

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Utterly Unbelievable: The Discourse of ‘Fake’ SOGI Asylum Claims as a Form of Epistemic Injustice

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Utterly Unbelievable: The Discourse of ‘Fake’ SOGI Asylum Claims as a Form of Epistemic Injustice

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Better Late Than Never? SOGI Asylum Claims and 'Late Disclosure' Through a Foucauldian Lens

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Better Late Than Never? SOGI Asylum Claims and 'Late Disclosure' Through a Foucauldian Lens

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X, Y and Z (European Union): Who is protected as queer refugee by the Court of Justice of the European Union?

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X, Y and Z (European Union): Who is protected as queer refugee by the Court of Justice of the European Union?

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Decolonizing Queer Migration: Iranian Voices in Exile

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Decolonizing Queer Migration: Iranian Voices in Exile

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Moira Dustin; Nuno Ferreira; Kamran Matin

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Recognising the needs of queer Iranian migrants

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Recognising the needs of queer Iranian migrants

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Moira Dustin; Nuno Ferreira; Kamran Matin

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30 recommendations for improving the lives of people claiming asylum on the basis of sexual orientation or gender identity (SOGI) in the UK

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30 recommendations for improving the lives of people claiming asylum on the basis of sexual orientation or gender identity (SOGI) in the UK

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30 recommendations for improving the lives of people claiming asylum on the basis of sexual orientation or gender identity (SOGI) in the UK

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It is now nearly forty years since the first SOGI asylum claims were recognised, and a great deal of progress has been made at a global and European level. There is increased awareness of SOGI persecution as well as examples of good policy and practice that should be publicised and replicated. However, alongside these, the SOGICA project found many areas where improvement is urgently needed, and we address these here. These recommendations largely reflect the views of almost 500 people, those who participated in the SOGICA project’s interviews, focus groups and online surveys.

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Coordination a group of trans children in Italy for the submission of their report to the UN Committee on the Rights of the Child in August;

Creation of  training for mediators on family mediation and LGBTQ+ people and training delivery in the UK and Italy;

Invited workshop delivery to family magistrates on family disputes involving LGBTQ+ partners and parents;

Contribution to a charity in Italy that focuses on the rights of trans and non-binary children, including writing for the media, and workshop organization on current legislative developments in Italy, and now working to organize first forum in Italy for trans and non-binary children and their families);

Previous membership of an Italian association of lawyers dedicated to LGBTIQ people, and involvement in strategic litigation, conferences, campaigning, including coordination of responses to policy around LGBTQ+ rights and inclusion.

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Which People with Bisexual Experience Identify as Bisexual? Insights from a Population-Representative Sample in Australia

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Which People with Bisexual Experience Identify as Bisexual? Insights from a Population-Representative Sample in Australia

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Transitioning HIV-negative men who have sex with men and transgender women diagnosed with early syphilis to HIV-pre-exposure prophylaxis

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Transitioning HIV-negative men who have sex with men and transgender women diagnosed with early syphilis to HIV-pre-exposure prophylaxis

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'There’s too many gay categories now': discursive constructions of gay masculinity

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'There’s too many gay categories now': discursive constructions of gay masculinity

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The role(s) transgender adults want general practice to have in their healthcare: a qualitative study in Southeast England

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The role(s) transgender adults want general practice to have in their healthcare: a qualitative study in Southeast England

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=326945

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Daisy Holland , Luka C. J. White , Marija Pantelic , Carrie Llewellyn

Transgender (trans) people experience health inequalities, which includes inequities in accessing and navigating healthcare systems. General practitioners (GP) in England have a limited role in delivering trans-specific healthcare. Few studies have explored what is positively working in GP-led primary care settings and how this can be more widely implemented. This study aims to explore the views and expectations of trans people regarding primary care services. Data were generated using qualitative semi-structured one-on-one interviews conducted with trans experts by experience who were recruited through purposive sampling. Results were analysed and coded using a thematic analysis framework to identify key themes. Positive and negative experiences of accessing and navigating general practice settings were identified by 16 trans people as experts by experience. An overarching theme was for gender-affirming services to be provided through general practice in order to reduce waiting times for specialist care and to move towards an informed consent model of care. Through demonstrating examples of good practice, general practitioners are advised to take a proactive role in providing positive gender-affirming healthcare for trans people. An informed consent model of care should be implemented to improve healthcare access.

Volume (Issue)

2(3-4)

Published

December 15, 2023

DOI

10.57814/w0e6-xy86

Copyright

© 2023. The Authors. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0)

Preferred Citation

Holland, Daisy, White, Luka C. J., Pantelic, Marija, Llewellyn, Carrie. 2023. "The Role(s) Transgender Adults Want General Practice to Have in Their Healthcare: A Qualitative Study in Southeast England." Bulletin of Applied Transgender Studies 2 (3-4): 175-194. https://doi.org/10.57814/w0e6-xy86

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In the United Kingdom, an estimated 600,000 people are trans, although this is likely to be an underestimation (Government Equalities Office 2018). As the sociocultural acceptance of trans people increases, general practitioner (GP) services within primary care are likely to care for an increasing number of trans individuals, who may be seeking advice or support in relation to gender-affirming healthcare (GAHC; Holden and Shrewsbury 2021). Access to GAHC includes interventions such as gender-affirming hormone therapy and gender-affirming surgery. A holistic approach should be taken whereby all trans individuals can choose to access any, or none, of the gender-affirming interventions available to them. This is irrespective of having a "binary" or nonbinary identity, co-occurring disability, or neurodivergence.

Through the National Health Service (NHS), access to GAHC is initially through primary care, in particular general practice, where the GP coordinates referrals to a gender identity clinic (GIC; NHS England 2019). At GICs, individuals are assessed by a psychiatrist to obtain a diagnosis of gender dysphoria, following which individuals may be referred for state-funded interventions such as hormone therapy, gender-affirming surgery, vocal coaching, fertility preservation and psychotherapy. The foundation of this model relies on the psychiatric assessment of trans individuals. Waiting times for GICs are extensive, with waiting times for an initial appointment in England reported between 26-74 months, with significant regional variation between GICs (Gender Construction Kit 2023). For comparison, the NHS referral-to-treatment waiting times at the end of April 2023 showed that of 7.4 million people awaiting to commence treatment, only 5% and 0.01% respectively were waiting more than 12 and 24 months for treatment (National Health Service, 2023). Consequently, many trans individuals' access GAHC privately or through self-medication (Ellis, Bailey and McNeil 2015, White et al. 2023). The limited availability of services and regional variation in service provision has been associated with travel costs and variability in the quality of care (Heng et al. 2018).

Trans people in the UK report a high rate of mental illness, including suicidal ideation, that can be attributed to discrimination, transphobia, and delays in accessing GAHC (Bachmann and Gooch 2018; Jones et al. 2019; Wright et al. 2018). Common experiences within primary care include GPs being unwilling to provide or support access to GAHC (Harrison et al. 2020; Snelgrove et al. 2012). The Trans Lives Survey 2021 found 57% of participants avoided healthcare settings when unwell, with 14% being refused care by a GP on account of being trans (TransActual 2021). Refusal by GPs to acknowledge the presence and healthcare needs of trans people adds to a collective sense of distrust by trans people accessing GAHC in the UK.

The role of primary care and, in particular, the GP in GAHC has evolved in recent years. The General Medical Council (2023; GMC) has guidelines for GPs in prescribing "bridging hormones" as part of a harm-reduction strategy whilst trans people are awaiting GAHC, supported by the Royal College of Psychiatrists and the World Professional Association for Transgender Health (Coleman et al. 2022). In addition, there have been several pilot projects providing GAHC access from a primary care-led perspective. These services are locally commissioned to provide assessments for gender dysphoria and services such as speech and language therapy, psychological support, referrals for hormone therapy, surgery, fertility preservation and hair-reduction. These include the Sussex Gender Service (Sussex), the Indigo Project (Greater Manchester), CMAGIC (Cheshire and Merseyside), Trans Plus (London), and the East of England Gender Service.

Trans communities have suggested establishing an informed consent model would improve access to care (Ellis et al. 2015; Schulz 2018; White et al. 2023). Informed consent emphasises self-determination for trans people and shared decision making between the healthcare practitioner (HCP) and trans individuals (Spanos et al. 2021). Following the principles of informed consent, trans individuals should be able to access GAHC so long as the associated risks and benefits of any intervention(s) are clearly understood, and the individual has capacity to consent. This is irrespective of whether any specific "gender transitioning" milestones have been met, or a GD diagnosis given, that would grant state-funded access to GAHC through a medical model. This would involve GPs having a more direct role in providing GAHC through localised, community-based services. With regard to this, the World Health Organisation (WHO) declassified being transgender as a mental or behavioural disorder in the International Classification of Diseases, 11th edition (ICD-11) in 2019 (Coleman 2022). There is now no basis for trans people to undergo psychiatric assessment and medical systems should be reformed as they are upholding a now outdated presumption and diagnosis (Allory 2020; Askevis 2019). By eliminating the requirement for a psychiatric diagnosis and assessment, primary care-led services could support the depathologisation of trans identities in favour of self-determination (Ashley 2019).

The aim of this study is to gain a better understanding from trans people, as experts by experience, into what GPs and other primary care services have done well and how this can be applied elsewhere. A secondary aim of this study is to gain more of an understanding of what trans people want their healthcare to look like, what areas of GAHC could be provided within primary care, and how GPs can implement or support this from a patient's perspective.

Methods

This qualitative interview study was developed as a result of steering group discussions regarding the locally commissioned service for trans healthcare (Sussex) about the increased need for academic research around GAHC and primary care for trans patients locally across the Sussex, UK region. A Sussex-based trans support organisation was approached for advice and support. A trans senior worker at the organisation (LW) designed and led the project. The research team also included two cisgender senior academics (CDL, MP) who supported with securing ethical approval, funding and overseeing the research process. A medical student (DH) was invited due to their previous postgraduate research on trans experiences of primary care (Holland et al. 2023). LW and DH took part in data collection and analysis and were both financially compensated for their input. All members of the research team were white and British. The team included researchers of a range of ages, and those who were queer and/or disabled and/or neurodivergent.

Study Design

A qualitative study was carried out using one-on-one semi-structured interviews with trans individuals within the southeast of England. Research was conducted and reported in line with the consolidated criteria for reporting qualitative research (COREQ; Tong 2007).

Sampling and Eligibility Criteria

Purposive convenience sampling was used to capture a range of views across people of different ages, genders, and racial identities. An aspirational quota was set to recruit greater than or equal to two trans people that were: older than 50 years, people of colour, transfeminine, transmasculine, nonbinary, and disabled and/or neurodivergent. "Transfeminine" here includes those who use the labels woman, trans woman, transfemme, or similar. "Transmasculine" includes those who use the labels man, transman, transmasc, or similar. We sought in the range of 10-15 participants for sufficient information power given the topics of interest and analysis (Malterud 2016). Participants were eligible if they were above 18 years old, trans, and eligible to receive healthcare across East and West Sussex. Exclusion criteria included those who could not speak English and/or could not give informed consent, whether verbal or written.

Recruitment and Procedure

Participant recruitment was facilitated by the trans community researcher (LW) working within the trans community. Advertisements were distributed to local charities and Sussex-based community organisations, as well as through the research team's social media. Individuals were invited to contact members of the research team via email. All prospective participants were distributed a consent form and a participant information sheet prior to interview. All participants were given the option of having a trans interviewer and a choice of online (via encrypted Zoom) or face-to-face interviews. It was emphasised that participation in this project had no influence on the support they received from any community organisations or from primary care services. Neither members of the community researcher's immediate personal network (i.e., friends and colleagues) nor individuals receiving individual support from them in a professional capacity participated in the study. Further purposive sampling of those with multiple marginalised identities was restricted by the time constraints of the project.

Interviews and Data Collection

Semi-structured interviews were designed and conducted in accordance with the process as set out by DeJonckheere and Vaughn (2019). Semi-structured interviews took place between October 2021 and January 2022. The two interviewers were DH and LW. Both interviewers were previously trained in qualitative methods. Both interviewers pilot tested the interview prior to the study to ensure there was a shared understanding between the interviewing team as to what type of language and interview style should be used.

Each interviewer conducted eight interviews each. At the interview, first demographic questions were asked before the consent form was read through with the participants. The audio recording was then switched on where participants were asked to state if they had read, understood, and agreed to the consent form. The maximum time for interviews was set to 60 minutes to support accessibility for disabled participants and researchers. All the interviews were digitally recorded and transcribed verbatim by hand using Microsoft Word by DH. Participants were assigned pseudonyms that were gender-neutral or in keeping with the common gendering of their names.

Ethical approval was granted by the Brighton and Sussex Medical School Research Governance and Ethics Committee on 27th October 2021 (ref no: ER/BSMS9923/1). All participants received a love2shop voucher of £20 for participation.

Topic Guide

Interviews were guided by a topic guide developed by the community researcher. The final version was pilot tested with DH and LW. Demographic questions were asked regarding participant's age, racial identity, their gender/relationship to gender, and whether they had a disability or were neurodivergent. The following domains were included in the topic guide: experiences of accessing GAHC; the impact of GAHC on health and wellbeing; views on the current GAHC pathway; and the role of the GP in GAHC-encompassing their views on what changes could be made to the current standard model of care. The topic guide had predetermined open-ended questions including: "What examples of trans affirming healthcare have you experienced in Sussex?" and "What impact has accessing gender-affirming healthcare had on your overall health and wellbeing?" Data collated through these interviews exploring the impact of the mixed provision of GAHC on the mental health of trans individuals has also been published (White et al. 2023). The topic guide had suggested additional follow-up questions and prompts to support the interviewers and ensure a similar, consistent approach across interviews.

Data Analysis

The data was analysed using the Ritchie and Spencer (1994) thematic framework analysis in six stages: familiarisation; coding; searching; reviewing; and defining themes; and reporting. Data analysis was conducted manually and independently by DH and LW. The coding framework and interpretation of results were discussed amongst the two researchers to establish a consensus. DH led in indexing and charting the data; LW and DH then began the interpretation process by exploring patterns in the data to extrapolate key themes. Interpretation of the results were discussed with the wider research team to reach a consensus and validate the findings.

Results

Twenty-one people contacted the research team. Sixteen were included in the study (Table 1). Two did not respond to email regarding an interview, one did not attend the interview, one dropped out of the study prior to interview, and one contacted the research team after we had ended participant recruitment. Interviews conducted had a duration of 31-74 minutes, with a median time of 50 minutes.

The aspirational quota set was met in recruiting participants in the following categories: trans feminine; nonbinary; disabled and/or neurodivergent. A significant proportion of participants were either white and/or trans feminine and/or 18-39 years of age. Further purposive sampling of communities of colour would have been preferred, however the research team were restricted due to time constraints.

Due to the richness of the data acquired and the separate research questions addressed, two papers resulted from this dataset. The first paper focuses on the mental health impact of current GAHC pathways in Sussex (White et al. 2023). The data contained in this paper focuses on the experiences and expectations of primary care and broader healthcare services, from which two key themes were identified: (1) trans experiences of accessing healthcare and (2) the trans-specific healthcare pathway. Key sub-themes are expanded upon below.

Transgender People's Experiences of Accessing Healthcare

General Practitioner (GP) knowledge

Participants described a range of positive, negative, and neutral experiences across primary and general healthcare. There were various factors which influenced how these experiences were perceived by respondents. GPs being knowledgeable about trans-specific healthcare positively shaped the outcome of the consultation. This included having a GP that had supported trans patients before, understood GAHC pathways and what services GPs could provide, proactively sought to acquire further knowledge, and/or understood the practicalities and limitations of accessing GAHC in England.

The best interaction in that I was getting valuable information, she's [the GP] obviously extremely well informed about trans healthcare and ... also approaches it in a very practical manner, like understanding where the healthcare system fails trans people a lot. A lot of us turn to self-medicating and things like.

-Matthew

A GPs proactiveness and willingness to learn were facilitators towards having a positive healthcare encounter, including advocating on behalf of the patient. However, participants described an initial apprehension to accessing primary care services due to the level of uncertainty around GPs understanding of GAHC.

Going to the doctors for one thing, which is something I felt uncomfortable about in the past... knowing that I have a GP who's friendly and listens to me and, you know, in a general sense, in a trans sense, who respects my identity, as well, as far as I can tell. Like, it makes me feel a lot more able to engage in healthcare and without that ... there's a good chance I think that I would withdraw a lot more and ... possibly allow healthcare issues to build up rather than say, deal with a GP who is not particularly respectful or acknowledging of my trans identity.

-River

Anticipation of a negative healthcare interaction was not uncommon, especially when there had been previous negative experiences with a GP:

Well, back in [location], what, I came out 2018? I had a very nice GP there who-she was just very nice and treated me like a normal person, which is always nice compared to like a GP I had before who would kind of just like look me up and down and make very objectifying observations.

-Jamie

GPs who had this knowledge base were better able to establish rapport and provide holistic support. This benefits trans patients in the short-term and fosters an environment where they feel as though they can return to a GP they trust, for both trans-specific and general healthcare. Participants who anticipated, then experienced, discriminatory attitudes, had their feelings of anxiety reinforced and associated with accessing healthcare. These negative interactions had a long-lasting impact where some participants were subsequently avoidant of accessing general healthcare; it was perceived as more harmful to their wellbeing.

My GP isn't so good. They're a bit old-fashioned. It's a little bit of a-it's quite a trigger when I go there. It's like, what's gonna happen today? Are they gonna be misgendering me in public?

-Candice

Some GPs continued to reinforce cisnormative gender stereotypes, to the extent some participants altered the way they dressed to better access GAHC without being challenged by GPs. Additionally, some participants recounted having been asked invasive personal questions, unrelated to their health, that were used by the GP to justify access to secondary care services.

To get on the GIC list I had to write a statement explaining why I felt that-you know, why I feel I was transgender and why I was seeking, you know, access to GIC. And basically, the GP told me that I needed to explain everything including, you know, my sex life and everything and that was very dehumanising to put that on paper and putting it on paper was, was very hard.

-Alex

Participants often felt forced into the role of patient educator, which ranged from educating GPs about trans identities to guiding GPs through GAHC guidelines, prescribing, and monitoring hormones and making referrals to secondary services.

I have to put time and effort into something that, really, I shouldn't have to do anything. It should be all on them. I mean, having to learn about dosages and names of certain drugs to tell my doctor what-I shouldn't have to tell them what I should be getting prescribed. They're a doctor. They should tell me. It's crazy.

-Candice

Some participants felt as though they had to prove they were "trans enough" to GPs as a prerequisite of accessing GAHC. This was also seen as GPs prioritising the potential political ramifications of providing GAHC above the welfare of trans people. This posed additional struggles for some participants who were nonbinary or gender-nonconforming; whose gender identity and/or expression directly challenged GPs assumptions as to what GAHC "should" look like.

I mean, as a gender-nonconforming person, as somebody who, like, I don't-personally, I don't wanna have surgery, I don't want hormones... And I think, yes, a lot of trans people do want surgery, want to go on hormones, trans people do wanna have surgeries, but I think there's almost a pressure to prove that you're trans enough? That you kinda have to want those things in order to be considered trans?

-Kai

Furthermore, some participants had difficulty defining key positive or negative healthcare encounters, but rather described their experiences as an absence of overt negativity:

Like, [the GP] still got my pronouns wrong, but at least he didn't call me miss or madame or lady.

-Kai

Many participants attributed limited GP knowledge to a lack of training regarding GAHC. The need for training was especially expressed in the context of increased waiting times for specialist care, meaning that the GP may be the only point of contact for support for many years. However, there was a perception that some GPs were unwilling to educate themselves about trans-specific healthcare and take responsibility. One participant described moving to a different surgery to access bridging hormones and reaching out to their former practice:

[The former GP] wanted his details from me, so that then she could refer anybody like me in the future to him, because that got her-that was a nice easy way for her to get off the hook for having to deal with anybody about bridging hormones. And I said, "well, do you wanna use me as a case study and work with [current GP] on this so you can get some training and some help and so that people like me in [location] can come to you and it will all be fine and you'll be able to prescribe bridging hormones and you can change your policy.?" No, no.

-Jo

This demonstrates there may be discriminatory behaviour within primary care through a reluctance to engage with trans individuals and through maintaining ignorance, despite awareness of training opportunities.

The patient-practitioner relationship

Participants' experiences of primary care were influenced by a perceived affirmation or rejection of their gender identity. Having a non-judgmental GP was regarded highly by respondents, with examples of gender affirmation including using the correct name, pronouns, and ensuring patient documentation reflected as such. Some participants described their expectations of ideal care as being able to take part in shared decision making that was more collaborative than hierarchical in nature.

I find that what's very important for me ... in my relationships with healthcare professionals is that the relationship is not a kind of paternalistic [one]... I contrast that with healthcare professionals who have a more collaborative approach who can-like, there is an equality to the relationship of sharing of their skills and knowledge with my knowledge of my body and desire to what health actually means in my life.

-River

If expectations of ideal care describe a deconstruction of power imbalances traditional within general practice, recognition is needed of the ways GPs hold power, on both a systemic and individual level. By being a common first point of contact for trans individuals, GPs can have a gatekeeping role in who gets access to specialist care. Some participants described a fear of disclosing health concerns unrelated to their gender identity for fear of their GIC referral or access to GAHC being taken away. This was more common amongst participants with multiple marginalised identities, especially those who had mental health issues, disabilities, or were neurodivergent.

I haven't disclosed any of my disabilities or mental health issues to the gender identity clinic cause I'm aware that they are much less likely to allow me to continue along the medical path I've gone down. It's also prevented me from getting myself properly tested for autism... 'cause I know it might make it harder for me to continue to procure hormones if I do so.

-Sam

On an individual level, some participants described feeling as though their health was not taken as seriously, and the GPs' lack of understanding meant their wellbeing was being disregarded.

It makes me feel quite down and quite, kind of, not being heard... You know, if I went to the doctors and said, "my arm has been hurting for years, could you help with my arm?" they'd go, "yeah I'll help you with your arm." But if I say "my gender's been hurting for years/ can you help my gender?" they just kinda go "meh, whatever."

-Kai

This demonstrates how important it is for trans people to feel as though they have greater agency in their own healthcare in equal partnership with a GP. It is important for GPs to recognise that trans people may be experiencing anxiety relating to previous or anticipated negative healthcare interactions. Being proactive in addressing possible concerns may help to increase trust and foster a more positive patient-practitioner relationship.

The Trans Specific Healthcare Pathway

The role of primary care in GAHC

A general perception amongst all participants was that GAHC should be primary care led. This included initiating hormone therapy and making referrals for fertility preservation, vocal coaching, laser hair removal, and both general and gender-based counselling. Participants felt better able to make informed, autonomous decisions about their healthcare in primary care, in collaboration with their GP.

I think the main positive experiences I've had is, like, being able to have an informed consent with a GP who has let me-he's given me suggestions for what I can do with my hormones without being strict on it, if that makes sense... I've just felt like I have a lot of control and options over it that have made it a much better experience for me.

-Sophie

Primary care-led services were perceived to be associated with a decreased waiting time compared to accessing GICs. Additionally, primary care was regarded as more accessible, with less travel requirements on the individual to access care.

There should be more, like, decentralisation of services so that the GPs have more power to get people directly onto what they need and, like, I don't know-I feel like if you're piling up all the services in a couple of central gender clinics around the country, it just, like, makes there be so many waiting lists and stuff. And, like, I get that that's probably how the legal system in the UK has set it up so that fewer trans people can get onto healthcare because that's kinda what they want.

-Gemma

Concerns were noted around the feasibility of GPs being able to provide GAHC. However, some participants expressed that by having more primary care-led services, GAHC may be regarded as less "niche" and GPs can take more direct responsibility for patient care and services they may eventually provide regardless.

At some point, even if you go through the GIC process, you get discharged from the GIC, and the ongoing management of your hormones for the rest of your life falls to your GP, so if they can do it then, why do I need someone else to hold their hand to start with?

-Emily

There were mixed experiences of participants already accessing some GAHC services across primary care. Some participants described being started on bridging hormones and being followed up for regular blood tests and monitoring by their GP. Some participants also reflected on their experiences trying to access fertility preservation on the NHS. None of the participants had accessed state-funded fertility preservation through primary care. However, some described their GP actively advocating on their behalf to local clinical commissioning groups or completing funding applications for those self-funding.

My advocate was brilliant and worked with trans people before and was really sensitive-just very kind of consensual about how every stage-and really, yeah, did the legal research to kind of advocate on my behalf to the NHS about why I should be able to receive hormone replacement therapy-sorry, fertility preservation-on the NHS prior to hormones.

-Melody

Allocating more services to primary care was therefore seen as an extension to care currently offered.

He [the GP] also referred me for voice therapy, which I had no idea... Making more people aware that they can get that through their GPs is really important.

-Sophie

A key priority for many participants was accessing hormone therapy and a GPs ability to initiate and monitor as such was regarded highly. There were mixed responses regarding surgical referrals within the remit of primary care. For some participants, surgical referrals were within the remit of the GIC as they were perceived as requiring more specialist input from secondary care. However, there was significant frustration with the current model of care, primarily the requirement for psychiatric assessment prior to being referred for state-funded surgery, and general waiting times. Moreover, some participants who thought surgical referrals should be GP-led associated as such with a shorter waiting time and greater accessibility.

It was annoying that I couldn't get my first appoint to see the surgeon until I'd actually got those two referrals [from psychiatrists] ... I would have liked to have had the opportunity to see the surgeon sooner.

-Emily

The role of the GIC and specialist services

There was a collective preference for an informed consent model in GAHC. Some participants expressed that, whilst the majority of GAHC could be primary care-led, there be circumstances whereby more specialist input could be required. Examples given included the potential need for endocrinological input when an individual does not respond to hormone therapy in a typical manner, the continued need for specialist surgical input, and the role of psychiatry in providing additional support to trans individuals with co-occurring severe mental illness.

It's all a bit bonkers, but we should be able to self ID. If we were, then the GIC would-literally all they would need to do is some mental health support, some hormone support for GPs in more serious cases in things, where it gets beyond the GPs knowledge, and surgery. That's it. They should be doing surgery referrals. That's basically all we need the GIC for.

-Ellie

The majority of participants wanted gender-affirming hormone therapy to be initiated through primary care. However, some participants wanted more of an opportunity to discuss their healthcare with an endocrinologist, particularly to discuss hormones, side-effects, and other considerations, such as fertility preservation treatments.

I think there should be... some kind of discussion you would have to have with maybe an endocrinologist explaining exactly what the effects will be, like explaining possible fertility treatments you can take beforehand.

-Sam

Another view was that gender specialists should be located across different hospitals with more dispersed clinics, similar to secondary care services, and this would be more locally accessible.

Well, I think there should just be gender specialists. I'm not sure there needs to be a gender clinic. I think if, you know... an ear, nose and throat specialist or... whatever you've got wrong with you in the health service, there's a specialist in every hospital, isn't there?

-Jo

Overall, trans individuals wanted to feel as though they were receiving practical advice and support rather than being psychologically assessed. Many participants felt as though this could be delivered through primary care where the GP was fully informed in GAHC pathways.

Discussion

Trans people experienced difficulties at all stages of healthcare access. The way GAHC is currently accessed in England is described by the participants as having a multitude of failings. These failings are putting the physical and psychological wellbeing of trans people at significant risk. There was an overall negative perception of accessing GAHC through primary care services and GICs with some positive experiences on an individual basis that speaks to systemic failings in GAHC provision. Additionally, recognising a good quality of care may be difficult in an environment where trans people anticipate negative reactions from healthcare providers and/or having to act as patient educator.

This is one of few studies to explore specifically positive experiences of GAHC access in primary care within the NHS. Previous studies have explored general healthcare (Heng et al. 2018; Teti et al. 2021), mental health (Ellis et al. 2015; Valentine 2018; White et al. 2023), GICs (Ellis et al. 2015; Taylor 2019), or experiences of healthcare in a non-NHS setting as a focus (Carlstrom et al. 2021; Guss et al. 2019; Ross et al. 2016). Participants from this study were additionally more likely to have accessed GAHC, such as bridging hormones, from primary care services, for which there are few studies, due to this region specifically having a Transgender Locally Commissioned Service (Sussex CCG 2021).

Multiple factors contributed to the difficulties accessing GAHC, such as a lack of GP knowledge regarding trans identities and healthcare needs, which corroborates findings from previous research. This includes anticipation of negative healthcare experiences and subsequent avoidance behaviour (Adams et al. 2013; Heng et al. 2018; Lerner et al. 2017). An additional study reported that trans individuals who had not accessed gender-affirming medication, such as hormone therapy, were more likely to experience distress discussing GAHC with their primary care doctor, including trans individuals who had no plans to seek medical intervention (Bauer, 2015). This was reflected by comments from participants of this study, where anxiety and stress stemmed from an anticipated rejection of their gender identity by GPs on the basis that they may not meet GPs preconceived ideas of what "counts" as being trans. For GPs, these preconceived ideas may be based on arbitrary social and/or medical transition "milestones," centred around the current model of care and requirement for a diagnosis of gender dysphoria, to access GAHC in England (NHS England 2019). The current NHS pathway for accessing GAHC does not reflect the diversity of gender identities and expression of trans people.

Many participants in this study reported negative experiences within primary care, which suggests a high prevalence of negative healthcare encounters. This is supported by the Trans Lives Survey 2021, where 70% of respondents reported transphobia when accessing healthcare (TransActual 2021). Regarding GICs, significant waiting times had a detrimental impact on participants health and wellbeing, which is reflected in trans peoples' broader experiences of GICs in the UK (Ellis 2015; McNeil et al. 2012).

The current model of care is perceived as paternalistic and pathologizing. This supports previous studies which have shown a general distrust of HCPs amongst transgender populations and a fear of disclosing physical and mental health concerns should they be used to deny access to GAHC (Ellis 2015). Previous research corroborates these findings that a supportive GP instils trust and improves mental health outcomes (Heng et al. 2018; McNeil et al. 2012).

Positive experiences and suggested solutions largely centred around themes of informed consent, self-determination, and working collaboratively in partnership with GPs. Under the current system in the NHS, participants emphasised proactivity and advocacy as a way GPs can have a large positive impact. This goes beyond an awareness of GAHC pathways but a knowledge of how to advocate and support trans people awaiting GIC appointments, including prescribing and monitoring bridging hormones and engaging with local transgender communities on how to improve GAHC access on a local and regional level.

With regards to expectations of ideal care, trans people wanted GPs to have a more involved role in GAHC service delivery. This is supported by frameworks as set out by the World Professional Association for Transgender Health (WPATH) which approves of an informed consent model as an alternative to required psychological assessment (Coleman et al. 2022). Studies evaluating pilot projects involving an informed consent model have generated high patient satisfaction rates (Ker 2020; Spanos et al. 2021). Whilst these pilot projects took place in Australia and New Zealand respectively, the findings from the studies showed participants associated these primary care-led services with increased accessibility, decreased waiting times and an overall depathologisation of trans identities; all themes which were associated with GP-led GAHC provision by participants in this study.

The requirement for trans people to undergo psychiatric assessment is rooted in supporting an outdated presumption and diagnosis (Coleman, 2022). As reinforced by the participants in this study, the current system requiring diagnostic assessment for GD furthers waiting lists, delays healthcare access and contributes to feelings of distrust and negative experiences within healthcare for trans people.

Primary care led GAHC was associated with greater accessibility, particularly for disabled, neurodivergent and/or working-class participants. This supports previous research highlighting geographical and socioeconomic inequality in accessing GAHC under the current care model (Heng et al. 2018). However, cisnormative attitudes in primary care isolated trans people, more so if they had other marginalised identities, emphasising the continued need for training amongst primary care staff. In particular, previous studies have shown racial discrimination negatively impacts healthcare outcomes for trans people of colour (Agenor et al. 2022; Howard et al. 2019). However, due to the low number of participants who were trans people of colour in this study, the additional impacts of racial biases were unable to be commented on.

The attitudes of GPs towards primary care-led GAHC services are mixed. Studies focusing on primary care-led GAHC services under an informed consent model have shown these services to be seen widely more positively, both from trans patients and clinicians (Reisner et al. 2015; Schulz 2018). There have been concerns expressed by some GPs about providing GAHC, seen as more "specialist" and thus beyond the remit of general practice (Crowley and Lacey 2021; Royal College of General Practitioners 2019). However, both the GMC and the Royal College of General Practitioners have published guidance and training modules available on GAHC and supporting trans patients under the current GAHC pathway (General Medical Council 2023; Royal College of General Practitioners 2019). Additionally, as expressed by many of the participants in this study, GAHC such as prescribing and monitoring hormones is the eventual responsibility of the GP following initiation of treatment through the GIC. Moreover, the generalised view of GAHC as "niche" may work to discriminate against trans people, as these views can be used by GPs to disengage with trans people entirely, including in the refusal to acquire additional training to meet the health needs of trans people.

Overall, normalising GAHC using a primary care-led informed consent model would depathologize trans identities. Trans individuals will be able to self-identify rather than having to prove their gender identity to GPs with cisnormative assumptions as to what it means to be trans. This is likely to increase the number of positive healthcare experiences trans people have in accessing GAHC. This is likely to improve the mental health of trans people in England but also individuals' overall health, as they are less likely to avoid general health services due to previous negative healthcare interactions.

Strength and Limitations

To the best of our knowledge, this is one of the first studies focusing on the positive experiences and expectations of primary care amongst trans individuals in England at a time when the introduction of the new NHS integrated care systems (ICS) may bring opportunity to reconfigure and commission new services. A key strength of this study is that it was co-produced and co-led with the trans community. This research also gave an opportunity for trans participants to express their ideas as to what they want GAHC pathways to look like in England through the publication of these findings.

The local Sussex NHS commissioning service has contributed to the training of local GPs in supporting trans patients in accessing healthcare. Therefore, this population group may have been more likely to have experienced both, or either, primary care led GAHC and/or standard referral to a GIC through the NHS (Sussex CCG 2021).

The sample used for this study was modest and self-selecting. The findings may have been strengthened from additional quantitative analyses exploring positive and negative experiences of primary care. The majority of participants were white and trans feminine which means valuable insights from people of colour and transmasculine people were missing from these data. Further purposive sampling of under-represented groups may have been achieved through a longer recruitment time. The community researcher was known by some of the participants as having a combined role as researcher, trans community member and worker at a trans support charity, which may have introduced participant bias and influenced some participant's responses. Their involvement may have served to increase participant trust in the project. To navigate this, close personal contacts and those receiving individual professional support from the community researcher were not included, and where possible the least known interviewer for each participant was chosen.

Implications for Clinicians and Policymakers

The role of the GP has been ill-defined in the context of delivering comprehensive trans specific healthcare. This continues to illicit confusion as to what trans people can expect from their GP and what care GPs understand they can provide. GPs should be made aware of the barriers and facilitators to accessing GAHC in England and their role in supporting trans patients. Under the current system, ways in which GPs can have a positive impact are through affirming one's gender, being aware of the GAHC pathway, and being proactive by signposting to relevant support services and taking additional training opportunities. GPs should be able to offer, or support early access to, hormone therapy, vocal coaching, laser hair removal and fertility preservation. This is not only in line with guidance from WPATH, but would also substantially improve trans people's mental health, especially when on extensive waiting lists under the current healthcare pathway.

Many participants accessed GAHC through private healthcare channels or through self-medicating. This creates a significant socio-economic class divide in who has access to GAHC (White et al. 2023), further exacerbated by the fact that trans people are at higher risk of homelessness and poverty (Government Equalities Office 2018; White 2015). Financial stress had a significant impact in participants lives, where continuing treatment may come at the expense of living or eating well. GPs are advised to be aware of ways to support trans individuals accessing GAHC. This may include signposting to local community support services or advocating on behalf of patients to access specialist services, such as enquiring to local clinical commissioning groups to fund fertility preservation.

On an institutional level, policymakers should consider moving away from psychiatric assessment as a precursor to GAHC access and implement an informed consent model of care in line with WPATH guidelines. This involves removing the need for a diagnosis of "gender dysphoria" or psychological evaluation to access GAHC. Trans people should be able to access early GAHC from their healthcare provider having understood the benefits and risks of any interventions. The development and evaluation of new ICS should be informed and evaluated by a representative sample of the trans community.

Areas for Future Research

Recommendations to improve access to GAHC in primary care can be evaluated, which may contribute to a growing body of evidence behind what influences positive healthcare experiences in primary care settings. Further research may include the perspectives of GPs in the facilitators and barriers to providing GAHC. Further research is needed as to the experiences of primary care by trans people with multiple marginalised identities in England, to ensure their voices are heard in commissioning and developing ICS using an intersectional framework. Additionally, there is limited research comparing the experiences of GAHC access both across different UK nations and between different regional locations in England.

Conclusion

There were difficulties in accessing GAHC by trans people that need to be addressed on an individual, institutional, and societal level. The experiences and expectations of trans people suggest healthcare provision should be more primary care led under an informed consent model. The current system by which GAHC is accessed in England is harmful to the health and wellbeing of trans people. There is a duty of care for GPs to be aware of trans-specific healthcare needs and take responsibility in advocating for trans patients, providing additional holistic support and advancing their knowledge.

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Acknowledgements

We would like to thank our participants for their willingness and openness in sharing with us their experiences of accessing gender-affirming healthcare. We would also like to thank the organisations who helped us with recruitment for this study. We received small seed funding for this study from Brighton University's Centre for Transforming Sexuality and Gender as well as the Individual Research Project student fund from Brighton and Sussex Medical School.

Table 1. Participant demographics ( N = 16)

# data[].attributes.attachment_link.authors[].name
[map[affiliation:map[bio:is a junior doctor. They received a BM BS in medicine and MSc in public health from Brighton and Sussex Medical School. Her research interests include gender-affirming healthcare provision and the role of primary care in transgender healthcare.'
 department: isni: organization: ror:] email:daisyholland30@gmail.com given_name:Daisy name:Daisy Holland orcid:<nil> surname:Holland] map[affiliation:map[bio:is an independent transgender community researcher. They received a BSc in medical science and an MSc in global health from Brighton and Sussex Medical School, and an MSc in psychology of mental health from the University of Edinburgh. They work as a freelance trainer and consultant and are involved in community and academic research into transgender health inequities.
 department: isni: organization: ror:] email: given_name:Luka C. J. name:Luka C. J. White orcid:Luka C. J. White surname:White] map[affiliation:map[bio:is a Lecturer in the Department of Primary Care and Public Health at Brighton and Sussex Medical School. She is a social epidemiologist focussing on the structural determinants of HIV, the public health impact of stigma, discrimination and marginalisation, and community engagement in research and evidence synthesis.
 department: isni: organization: ror:] email: given_name:Marija name:Marija Pantelic orcid:<nil> surname:Pantelic] map[affiliation:map[bio:is the head of Department of Primary Care and Public Health at Brighton and Sussex Medical School. She is a Professor of Applied Behavioural Medicine, a Chartered Psychologist, and Associate Fellow of the British Psychological Society. She has a research interest in LGBTQI+ health inequities.
  
 department: isni: organization: ror:] email: given_name:Carrie name:Carrie Llewellyn orcid:<nil> surname:Llewellyn]]

# data[].attributes.attachment_link.title
The Role(s) Transgender Adults Want General Practice to Have in Their Healthcare: A Qualitative Study in Southeast England

# data[].attributes.attachment_link.description
Transgender (trans) people experience health inequalities, which includes inequities in accessing and navigating healthcare systems. General practitioners (GP) in England have a limited role in delivering trans-specific healthcare. Few studies have explored what is positively working in GP-led primary care settings and how this can be more widely implemented.

# data[].attributes.headline
The NHS England Fundamental Information Standard for Monitoring Sexual Orientation

# data[].attributes.subject
The NHS England Fundamental Information Standard for Monitoring Sexual Orientation

# data[].attributes.headline
The experiences of transgender and nonbinary adults in primary care: a systematic review

# data[].attributes.subject
The experiences of transgender and nonbinary adults in primary care: a systematic review

# data[].attributes.headline
Sexual orientation disclosure in healthcare: systematic review

# data[].attributes.subject
Sexual orientation disclosure in healthcare: systematic review

# data[].attributes.body
https://elements.sussex.ac.uk/viewobject.html?cid=1&id=184861

# data[].attributes.attachment_link.title
Sexual orientation disclosure in health care: a systematic review

# data[].attributes.attachment_link.description
Background Significant health disparities between sexual minority individuals (that is, lesbian, gay, bisexual, or transgender [LGBT]) and heterosexual individuals have been demonstrated. Aim To understand the barriers and facilitators to sexual orientation (SO) disclosure experienced by LGBT adults in healthcare settings. Design and setting Mixed methods systematic review, including qualitative, quantitative, and mixed methods papers following PRISMA guidelines.

# data[].attributes.headline
Que(e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education

# data[].attributes.subject
Que(e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education

# data[].attributes.body
https://elements.sussex.ac.uk/viewobject.html?cid=1&id=248262

# data[].attributes.attachment_link.title
Que(e) rying undergraduate medical curricula: a cross-sectional online survey of lesbian, gay, bisexual, transgender, and queer content inclusion in UK undergraduate medical education - BMC Medical Education

# data[].attributes.attachment_link.description
Background Lesbian, Gay, Bisexual, and Transgender (LGBT) individuals are more likely to have negative healthcare experiences and worse health outcomes when compared with their heterosexual and cisgender counterparts. A key recommendation of the 2018 Stonewall-commissioned “LGBT in Britain” report was that the curricula, standards, and training provided by medical schools should be reviewed in order to encompass mandatory teaching about LGBT health inequalities and discrimination, LGBT-inclusive care and the use of appropriate language. The aim of our study was to conduct an in-depth national review of the content of LGBT teaching within the curricula of UK Medical Schools. Methods Course leads at all 37 UK Medical Schools with students currently enrolled in a primary undergraduate medical training course were asked between December 2019–March 2020 to complete a cross-sectional online survey comprised of 30 questions; divided into three sections relating to the current LGBT teaching (Part 1), any planned or future LGBT teaching (Part 2), and the opinions of the survey respondent about the coverage of LGBT topics (Part 3) at their institution. Responses were analysed using descriptive statistics. Results Questionnaires were received from 19/37 institutions (response rate: 51%). The median estimated number of hours of LGBT-teaching across the entire undergraduate course was 11.0 (IQR: 12.25). Teaching on LGBT mental health, gender identity, sexual orientation, awareness of LGBT-health inequalities, and LGBT discrimination in healthcare were reported by almost all respondents, whilst maternity and childbirth, chronic disease and LGBT adolescent health were least represented within the curriculum. Almost all (18 medical schools; 95%) responding institutions were considering implementing new LGBT teaching within the next three academic years. A lack of space within the curriculum is a universally reported barrier to the implementation of LGBT teaching. Only 5 (26%) survey respondents consider their institution’s current coverage of LGBT topics to be “Good” or “Very good”. Conclusion Our study demonstrates a significant variation in the amount and breadth of content within the undergraduate curricula of UK medical schools. Recommendations for increasing the quantity and quality of LGBT content are provided, based upon areas of good practice.

# data[].attributes.headline
Prevalence of cancer risk factors among transgender and gender diverse individuals: a cross-sectional analysis using UK primary care data

# data[].attributes.subject
Prevalence of cancer risk factors among transgender and gender diverse individuals: a cross-sectional analysis using UK primary care data

# data[].attributes.body
https://elements.sussex.ac.uk/viewobject.html?cid=1&id=312013

# data[].attributes.attachment_link.readable_text
Background Transgender and gender diverse (TGD) individuals experience an incongruence between their assigned birth sex and gender identity. They may have a higher prevalence of health conditions associated with cancer risk than cisgender people.

Aim To examine the prevalence of several cancer risk factors among TGD individuals compared with cisgender individuals.

Design and setting A cross-sectional analysis was conducted using data from the UK's Clinical Practice Research Datalink to identify TGD individuals between 1988-2020, matched to 20 cisgender men and 20 cisgender women on index date (date of diagnosis with gender incongruence), practice, and index age (age at index date). Assigned birth sex was determined from gender-affirming hormone use and procedures, and sex-specific diagnoses documented in the medical record.

Method The prevalence of each cancer risk factor was calculated and the prevalence ratio by gender identity was estimated using log binomial or Poisson regression models adjusted for age and year at study entry, and obesity where appropriate.

Results There were 3474 transfeminine (assigned male at birth) individuals, 3591 transmasculine (assigned female at birth) individuals, 131 747 cisgender men, and 131 827 cisgender women. Transmasculine people had the highest prevalence of obesity (27.5%) and 'ever smoking' (60.2%). Transfeminine people had the highest prevalence of dyslipidaemia (15.1%), diabetes (5.4%), hepatitis C infection (0.7%), hepatitis B infection (0.4%), and HIV infection (0.8%). These prevalence estimates remained elevated in the TGD populations compared with cisgender persons in the multivariable models.

Conclusion Multiple cancer risk factors are more prevalent among TGD individuals compared with cisgender individuals. Future research should examine how minority stress contributes to the increased prevalence of cancer risk factors in this population.

Transgender and gender diverse (TGD) individuals experience an incongruence between their assigned sex at birth and gender identity. Little research has been conducted on the prevalence of cancer risk factors among TGD individuals. In this analysis using primary care data it was found that factors such as smoking, alcohol use, obesity, dyslipidaemia, diabetes, and HIV and hepatitis infections are elevated among TGD persons, likely due to the increased stigma and discrimination this population faces. Awareness of the higher prevalence of these risk factors among TGD people can enable GPs to offer more opportunistic patient education and investigation.

Statistical analyses

The prevalence of each risk factor by gender identity was estimated using Poisson regression with sandwich estimator for factors with high prevalence (all except for viral infection outcomes) or log binomial regression to yield the prevalence ratio (PR) with a 95% confidence interval (CI)., All models were adjusted for continuous index age and continuous index year. Models were further adjusted for dyslipidaemia and diabetes, and for obesity.

Sex assigned at birth was determined from the medical record based on a combination of gender-affirming hormone therapy and procedures, and sex-specific diagnosis terms (see Supplementary Tables S5-S7). Because the authors were unable to identify the sex assigned at birth for a total of 3725 TGD individuals, multiple imputation was performed for missing values in sex assigned at birth, in addition to missing values for BMI, alcohol use, and smoking status based on height, weight, index age, index year, and all cancer risk factors. Multiple imputation was performed using proc MI in SAS (version 9.4) to create five imputed datasets. PROC SURVEYFREQ and PROC MIANALYZE (SAS, version 9.4) was used to obtain pooled frequencies and proportions. In a sensitivity analysis, frequencies, proportions, and PRs were reported without imputation. The analysis where sex assigned at birth was imputed but individuals with missing smoking use, alcohol use, and/or BMI data were excluded are also reported. All counts less than five are suppressed per CPRD policy to protect privacy. All analyses were carried out in accordance with CPRD guidelines and regulations.

This work is a collaboration between authors who are researchers, community organisers, advocates for, and members of the TGD community. TGD insight was instrumental during the design and execution of this research. This analysis was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

Summary

In this large analysis using primary care data, it was found that there is an increased prevalence of cancer risk factors among TGD individuals. Transmasculine individuals showed an elevated prevalence of obesity, smoking, dyslipidaemia, and hepatitis C infection compared with cisgender women and an elevated prevalence of obesity, current alcohol use, diabetes, and HIV infection compared with cisgender men. Transfeminine individuals showed elevated prevalence of smoking, dyslipidaemia, diabetes, and hepatitis B, hepatitis C, and HIV infections compared with cisgender women, but a decreased prevalence of obesity.

Transfeminine people also showed elevated dyslipidaemia, hepatitis C infection, and HIV infection compared with cisgender men. These findings suggest that minority stress due to stigma and discrimination, in addition to factors like hormone use, may increase comorbidity risk.

Strengths and limitations

A strength of this study is the inclusion of TGD individuals using diagnosis codes for gender incongruence and not exclusive to those receiving gender-affirming care such that the results may be more generalisable to the wider TGD community engaged in health care. However, as TGD people are less likely to engage with the medical system than cisgender people, ⁻, these results may not be generalisable to all TGD adults in the UK. Diagnosis codes and medications were used to define many of the risk factors of interest, which are likely to be more accurate than self-report.

A limitation of this study is that TGD identity was inferred based on gender incongruence codes and assumed sex assigned at birth through electronic medical record information, as opposed to self-reported gender identity as is the gold standard. Relying on diagnosis codes for gender incongruence may miss people who have not disclosed to their providers or who do not seek medical transition.

Furthermore, the prevalence ratios may be inflated if clinicians were more likely to ascertain health history from TGD persons than cisgender persons due to ascertainment bias. The prevalence of some conditions may have been underestimated by using diagnosis codes and medications rather than laboratory values. Lastly, the authors were unable to adjust for important confounders, including socioeconomic status, race/ethnicity, income level, physical activity, and immigration status due to the lack of documentation of these factors in CPRD.

In this article, the terms transmasculine (assigned female at birth) and transfeminine (assigned male at birth) have been used to best represent the potential gender diversity captured by the study's inclusion criteria. Terminology used by clinical and TGD populations can vary, with the most widely accepted terms often being introduced and upheld by the latter. This, along with the study's intention to balance inclusivity and specificity, forms the rationale for the choice of terminology. Due to the nature of the CPRD data it is difficult to reliably identify and report on non-binary identities. The authors recognise this limitation and acknowledge that this should be addressed in future research.

Comparison with existing literature

Current literature suggests that transmasculine individuals experience an increase in body mass related to hormone therapy.,, However, the increased prevalence of obesity among this population compared with cisgender individuals may also involve social and environmental factors such as living in poverty or reduced physical activity., Changes to lipid profiles shortly after initiating gender-affirming hormone therapy have been documented in transfeminine and transmasculine adults and adolescents., Specifically unfavourable changes, such as an increase in total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels along with a decrease in high-density lipoprotein cholesterol levels was observed for transmasculine individuals. However, these changes may not necessarily equate to poor cardiovascular outcomes.

A systematic review of TSG individuals on gender-affirming hormone therapy, showed very few deaths due to stroke and myocardial infarction, especially among transgender men. The present study found higher diabetes prevalence among TGD individuals compared with cisgender individuals; however, studies from Europe and the US have found no increase in diabetes prevalence among TGD populations. ⁻

Previous studies have shown higher tobacco use among TGD individuals compared with cisgender individuals.,, In this study, the cohort includes patients seeking primary health care, many of whom are seeking gender-affirming care that may require cessation of smoking. Regarding alcohol use, a decreased prevalence of self-reported alcohol use was observed among Veterans Health Administration TSG patients in the US; however, the same study also found an increase in alcohol use disorder diagnoses relative to cisgender patients. Likewise, Hughto et al showed that TGD individuals had a higher prevalence of alcohol use disorder diagnoses compared with cisgender people. It is possible that the findings from the present study that former alcohol use is elevated among transmasculine individuals reflects abstinence following an alcohol use disorder diagnosis.

This study also found that the prevalence of HIV infection was two to six times higher among TGD individuals than cisgender individuals. Additionally, hepatitis C infection was two to three times higher among TGD individuals compared with cisgender women. Increased prevalence, incidence, and diagnosis of HIV infection may be due to engaging in condomless sexual intercourse, possibly in the context of survival sex work and/or injection drug use. ⁻ The population included in the present study had a low overall prevalence of HIV compared with national estimates of 0.46-4.78 per 1000 TSG persons, likely due to the study population being engaged with primary care and potentially more aware of prevention measures. However, these data suggest that the HIV and hepatitis C epidemics for TGD persons, particularly transfeminine individuals, are still ongoing and that targeted interventions are needed to reduce the number of newly acquired infections each year.

Implications for research and practice

Chronic health conditions may be increased among TGD patients for a number of reasons, including, but not limited to, minority stress due to societal discrimination and stigma. Chronic stress from institutionalised stigma and social norms results in TGD individuals' rejection of healthcare needs as a priority, resulting in worse health outcomes.,, GPs should be aware of the increased risk of chronic conditions among TGD patients to provide proper prevention and treatment. For example, the increased prevalence of smoking and alcohol use among TGD patients in this study cohort suggests that harm reduction or cessation counselling in primary care settings may significantly benefit TGD patients.

Additionally, GPs should be aware that a significant amount of discrimination occurs in healthcare settings, with more than half of TGD people reporting avoiding going to a doctor when feeling unwell. A 2021 survey of almost 700 TSG individuals in the UK found that 70% experienced transphobia in medical settings and 14% reported being refused health care (of any kind) by a GP for being transgender. These instances were more common for non-binary and Black people and people of colour. Consequently, TGD individuals may delay addressing their healthcare needs in the face of this stigma and stress, resulting in worse health outcomes. GP practices may wish to undertake additional training for all staff to address discrimination. ⁻ Awareness of delayed presentations by TGD people may enable GPs to offer more opportunistic patient education or investigation when patients do present.

This analysis of TGD individuals in primary care found an elevated prevalence of at least one risk factor for cancer, including viral infections, such as HIV, as well as diseases of metabolic origin, like obesity, diabetes, and dyslipidaemia. Reasons impacting the presence of these risk factors may include social and environmental determinants of health that remain underaddressed in this population. Further longitudinal research is required to elucidate the factors driving the increase of these morbidities and if these factors result in increases in diseases like cancer in this population.

Funding

This study was funded by the Intramural Research Program of the National Cancer Institute.

Ethical approval

This study is based on data from the February 2020 Clinical Practice Research Datalink (CPRD) GOLD and Aurum database releases (obtained under license from the UK Medicines and Healthcare products Regulatory Agency; the data are provided by patients and collected by the NHS as part of their care and support). The interpretation and conclusions of this analysis are those of the authors alone. GPs do not require patient consent when sharing data with CPRD, though patients have the option of opting out, as CPRD data are anonymised. This study was approved by the CPRD Independent Scientific Advisory Committee (proposal #19_177) and exempted from full institutional review board review by the National Institutes of Health Office of Human Subjects Research.

Data

The data that support the findings of this study are available from CPRD, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available with permission of CPRD.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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# data[].attributes.attachment_link.title
Prevalence of cancer risk factors among transgender and gender diverse individuals: a cross-sectional analysis using UK primary care data

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Background Transgender and gender diverse (TGD) individuals experience an incongruence between their assigned birth sex and gender identity. They may have a higher prevalence of health conditions associated with cancer risk than cisgender people. Aim To examine the prevalence of several cancer risk factors among TGD individuals compared with cisgender individuals.

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Perceptions of gay men’s masculinity are associated with sexual self-label, voice quality and physique

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Perceptions of gay men’s masculinity are associated with sexual self-label, voice quality and physique

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Patient sexual orientation and gender identity disclosure

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Patient sexual orientation and gender identity disclosure

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Partners of bisexual fathers: feelings about bisexuality and experiences of family life

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Partners of bisexual fathers: feelings about bisexuality and experiences of family life

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=377395

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Objectum sexuality: a sexual orientation linked with autism and synaesthesia

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Objectum sexuality: a sexual orientation linked with autism and synaesthesia

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=138667

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Abstract

Objectum-sexuality (OS) is a sexual orientation which has received little attention in the academic literature. Individuals who identify as OS experience emotional, romantic and/or sexual feelings towards inanimate objects (e.g. a bridge, a statue). We tested 34 OS individuals and 88 controls, and provide the first empirical evidence that OS is linked to two separate neurodevelopmental traits - autism and synaesthesia. We show that OS individuals possess significantly higher rates of diagnosed autism and significantly stronger autistic traits compared to controls, as well as a significantly higher prevalence of synaesthesia, and significant synaesthetic traits inherent in the nature of their attractions. Our results suggest that OS may encapsulate autism and synaesthesia within its phenomenology. Our data speak to debates concerning the biological underpinnings of sexuality, to models of autism and synaesthesia, and to psychological and philosophical models of romantic love.

Introduction

Categories or continua of sexual orientation are recognised in social, psychological, political and biological sciences. One orientation almost entirely absent from this research arena is objectum-sexuality (OS; also known as objectophilia). OS individuals describe experiencing emotional, romantic and/or sexual feelings towards inanimate objects or structures. For example, Eija-Riitta Berliner-Mauer has described her romantic attraction towards the Berlin Wall1 and others have written similarly about their feelings towards a range of objects (e.g., a bridge, a fence, a statue, an electronic soundboard)2. Our background in synaesthesia3,4 and autism5,6 led us to recognise potential features of both conditions from anecdotal descriptions given by OS individuals-and these features have also been noted by others7. For example, one survey7 found that a high number of OS individuals (six out of 21) anecdotally reported autism, a set of neurodevelopmental traits that encompass difficulties in social communication, repetitive/routine behaviours, special interests, and sensitivity to sensory stimuli8. Although this earlier survey included no significance tests or baselines, it is possible calculate the prevalence of autism within that OS group (28.57%), and this is significantly higher than the general population estimate of 1.46%9 (χ ²(1) = 16.14, p < 0.001, 95% CI [0.09, 0.50]). Another neurodevelopmental trait potentially relevant to OS is synaesthesia10, which affects around 4% of the general population11 but occurs at higher rates in autism6,12,13. Synaesthesia gives rise to an unusual fusing of sensations-for example, experiencing a sense of colour when reading letters or numbers ( grapheme-colour synaesthesia 14). Important for our purposes here, is that some forms of synaesthesia imbue inanimate objects with genders or personalities. Hence people with object-personification synaesthesia 15,16 might feel that their house-keys are female, or that their pocket watch is shy. Other triggers are linguistic sequences such as letters and numbers (e.g., J might feel motherly, 7 might feel selfish; and this is known as grapheme-personification synaesthesia or ordinal linguistic personification 4,17). These synaesthetic personifications have known neurological roots16,18 and are reminiscent of descriptions given anecdotally by OS individuals about the objects they are attracted towards. Given the potential overlap between OS, autism, and synaesthesia, our study is the first to explore the relationship among them, using empirical behavioural testing.

In our study we tested 34 self-identified OS individuals and 88 controls, using questionnaires and objective measures related to OS, autism and synaesthesia. If OS is linked with autism, we predict significantly higher rates of diagnosed autism in our OS group, compared to controls and population baselines9. We will also use the Autism Spectrum Quotient19 (AQ) to measure autistic traits, and predict that the OS group will show significantly higher autistic traits compared to controls. We will also investigate a possible link between OS and synaesthesia, and make several predictions. If OS is linked with synaesthesia, we first predict that OS individuals should describe complex personality traits for their object-partners, similar to those found in object-personification synaesthesia15,16. These complex synaesthesia-like percepts should also be consistent over time, which is the 'gold standard' hallmark of synaesthesia20,21 (i.e., genuine synaesthetic associations remain unchanged when repeatedly probed). We therefore followed widely-accepted synaesthesia protocols3,22 to determine whether OS individuals show the synaesthetic hallmark of consistency-over-time in the personalities they attribute to objects. To do this, we first asked OS individuals whether they felt personifications in their object-partners (i.e., the objects they were attracted towards). We then assessed the consistency of these personifications by giving a surprise retest 30 minutes later. In our test and retest, OS individuals described their object-partners using 44 personality adjectives (e.g. outgoing, conscientious, artistic) which they rated on a 5-point Likert scale from "Definitely disagree" to "Definitely agree". This approach maps personality into five dimensions ( Openness to Experience, Contentiousness, Extraversion, Agreeableness, Neuroticism 23) based on the Big-5 personality model24. Control participants were asked to invent personifications for their "most-loved or favourite object" via the everyday mechanisms of anthropomorphism (i.e., the common tendency to attribute humanlike characteristics to nonhuman agents; e.g., "I love my car but she's temperamental"). In summary, both groups described personalities for objects in a test and retest, and we compared each group's consistency-over-time (a hallmark of synaesthesia).

If OS is linked with synaesthesia we also predict that OS individuals may show a more general synaesthetic phenotype, and therefore present with additional forms of synaesthesia. Epidemiological studies show that multiple forms of synaesthesia tend to co-occur within the same individual3. For example, synaesthetes with grapheme-personification synaesthesia have significantly elevated rates of grapheme-colour synaesthesia17. We therefore screened our participants for two additional forms of synaesthesia, using objective diagnostic tests for grapheme-personification synaesthesia25 and grapheme-colour synaesthesia26. We chose grapheme-colour synaesthesia because it is the most widely tested and well-understood variant of synaesthesia and we chose grapheme-personification synaesthesia because it shows phenomenological similarities with object personification. If OS is related to synaesthesia, we predict higher rates of these synaesthesias within OS individuals.

In summary, if OS is linked with autism, we predict higher rates of autism diagnosis and autism traits in OS individuals, compared to population and control baselines. If OS is linked to synaesthesia, we predict that OS individuals will experience complex personality traits for their admired objects (as found in object-personification synaesthesia), a high level of consistency when describing these personality traits (as found in synaesthesia more broadly), and a higher prevalence of other synaesthesias (grapheme-personification or grapheme-colour synaesthesia) compared to population and control baselines.

Methods

Participants

We tested 122 participants comprising 34 OS individuals (18 female, 5 male, 11 other; mean age 32.85, range 17-67, SD = 12.88) and 88 controls without OS (63 female; mean age 19.15, range 18-24, SD = 1.18). OS is extremely rare and our study recruited the largest cohort of this population in the scientific literature to date. Power analyses showed that 20 OS participants and 50 controls would be sufficient to detect differences between two independent proportions (e.g., comparing autism diagnoses across groups) with 80% power, using a previous prevalence of autism in OS of 28.57%7. Likewise, 23 OS participants and 59 controls would be sufficient for detecting mean differences between two independent groups (e.g., comparing AQ differences across groups) with 80% power, with a predicted medium-to-large effect size ( d  = 0.7). Here, a medium-to-large effect size is considered reasonable given that we expect OS participants to score highly on tests of autism symptoms, and in consistency for object-personalities (see below).

OS individuals were recruited from online communities of individuals self-identifying as OS (e.g., www.objectum-sexuality.org). Controls were recruited from the University of Sussex community and participated for course credit. The OS group were older than controls ( t(33.21) = −6.20, p < 0.001) but this difference falls in a conservative direction (i.e., the traits we seek in OS decrease rather than increase with age27,28,29,30). Subsets of OS participants (n = 23-34) completed different elements of our study so we preface our methods below with participant numbers for each test. Participants were tested via our online testing portal ( www.syntoolkit.org) accessed via a link embedded within our digital recruitment postings. To avoid recruitment bias neither the advert nor information sheet mentioned synaesthesia or autism. Our study was approved by the Cross-Schools Science and Technology Research Ethics Committee at the University of Sussex and the study was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All participants provided their full informed consent prior to taking part in the study.

Materials and Procedure

Participants completed the following tests (in the order described further below):

Autism screening

[Part 1] Participants (n = 34 OS; n = 88 controls) were asked whether they had received a " formal diagnosis of a developmental disorder in the past?" with button options given as " Autism, Asperger Syndrome, Pervasive Developmental Disorder Not Otherwise Specified, Other, None". Participants were also given the opportunity to provide any further details about their autism diagnosis in an optional text-box. [Part 2] Participants also completed the Autism Spectrum Quotient 19 ( AQ; n = 26 OS; n = 88 controls) which is a 50-item questionnaire measuring autistic traits in adults along five subscales: Social Skills, Attention Switching, Attention-to-detail, Communication and Imagination. Example items include " I find it difficult to work out people's intentions", and " I tend to notice details that others do not". Participants respond to each statement on a 4-point Likert scale ( Definitely Agree, Slightly Agree, Slightly Disagree, Definitely Disagree). Approximately half the questions are reverse coded. Items are scored 1 point if the participant records an autistic trait (e.g., poor Social Skill, good Attention-to-detail) using the 'slightly' or 'definitely' response. Scores can range from 0 to 50 with a score of 32 or above recognised as a strong indicator of likely autism19.

Sussex Objectum-Sexuality Questionnaire (SOSQ; n = 34 OS; n = 88 controls) is an in-house measure which first allows participants to self-declare as OS with the question: " Do you feel romantic and/or sexual attraction towards objects?: Yes, No ". Participants answering NO to this question are assigned to the control group and are automatically taken to the next stage of study. Participants answering YES are assigned to the OS group and they completed several follow-up OS-related questions (to be reported elsewhere).

MULTISENSE Test for Object-personification synaesthesia is an in-house synaesthesia diagnostic based on a previously validated methodology25. This diagnostic determines whether individuals experience personifications for non-human objects and whether they show the synaesthetic trait of consistency-over-time (i.e. a high level of consistency in describing the personality of objects over time would suggest their experiences represent object- personification synaesthesia). Part 1 begins for OS participants with the question " Do you think that your current or most recent object partner/attraction has any personality characteristics?: Yes, No". Participants who answer "Yes" complete a personality questionnaire24 consisting of 44 randomly ordered personality traits (e.g. outgoing, conscientious, artistic) which OS participants rated to describe their object-partner using a 5-point Likert scale ( "Disagree strongly; Disagree a little; Neither agree nor disagree; Agree a little; Agree strongly"). Controls were given the same questionnaire but were asked to invent a personality profile for their " most-loved or favourite object" (e.g. a favourite chair). In Part 2, all participants repeated the personality questionnaire a second time (and this took place later within the same session; see below) as a surprise retest. The purpose of this surprise retest was to determine the consistency of participants' responses, given that high consistency is the marker for object-personification synaesthesia15. Twenty-three OS participants and 88 controls completed both parts of this test.

MULTISENSE Test for Grapheme-personification synaesthesia is a validated diagnostic of grapheme-personification synaesthesia and the full procedure is to be reported elsewhere25. As in the test above, this diagnostic determines whether individuals experience personifications (this time for graphemes) and whether they are consistent over time (a hallmark of grapheme-personification synaesthesia). Participants (n = 27 OS; n = 88 controls) began with the opportunity to self-report grapheme-personification synaesthesia from the question " Do you tend to think of letters or numbers as being like people (i.e. do you associate them with specific personalities or genders, and have always done so before today)?: Yes, No ". Participants were then asked to indicate whether their pre-existing personifications were for numbers, letters or both (and if both, which was the strongest). Participants then completed a test of consistency in which they saw either numbers 0-9, or letters A-Z, according to their earlier response: i.e., subjects who responded YES to our self-report question were shown whichever set of graphemes (numbers vs. letters) they reported as triggering personalities, or triggering them strongest; controls were randomly allocated to either set. For the purposes of our study all participants completed this test regardless of whether they indicated experiencing grapheme-personification synaesthesia or not.

During the consistency test, graphemes were shown one-by-one in a random order, and participants were required to rate the personality of each grapheme using an adjustable pie-chart of five personality descriptions ( imaginative, thorough, outgoing, trusting, handles stress well; see Fig. 1, left panel) one for each factor of the Big-5 personality model24. Participants rated the relative contribution of each trait to the overall personality profile of the grapheme (e.g., This grapheme is 40% imaginative, 20% thorough, 5% outgoing, 10% trusting, 25% handles stress well). Participants also rated the gender of each grapheme from "very male" to "very female" on a 5 point Likert scale. Participants could also select no personality and/or no gender if they did not experience a personality or gender for a particular grapheme, although participants were instructed to avoid pressing these buttons as much as possible (because we wanted a consistency score for both OS individuals and controls). Each grapheme was displayed twice in a block design resulting in 20 trials for numbers (i.e., 2 × 10), or 52 trials for letters (i.e., 2 × 26). The test generated two output measures, indicating how consistently participants described the personality or gender of their graphemes. Following validated procedures25, we calculated consistency (for personality and gender scores separately) by regressing participants' responses for their first set of personality and gender descriptions against their second set of descriptions. This indicated the degree to which the first set of descriptions were a predictor of the second set of descriptions (as a measure of consistency). Synaesthetes were diagnosed as those scoring at or above the validated threshold for synaesthesia, which was again computed separately for personality ratings and gender ratings. A diagnostic threshold for synaesthesia of ≥34.97 was used for personality scores, while a diagnostic threshold of ≥82.69 was used for gender scores31.

Left panel shows an example trial from our grapheme-personification synaesthesia diagnostic. Participants adjust the segments of the pie-chart to select the personality of the presented grapheme. Participants also used the Likert scale to describe a gender for each grapheme. Right panel shows an example trial from the grapheme-colour synaesthesia diagnostic. Participants adjust the colour-picker to select the associated colour for each presented grapheme. In both cases (left and right panels) graphemes are presented twice (in a test and retest) and we calculate the synaesthetic measure of consistency-over-time. High consistency is the hallmark of synaesthesia.

MULTISENSE Test for Grapheme-Colour synaesthesia is an in-house version of the widely-validated3,22,32 diagnostic for grapheme-colour synaesthesia. Its procedure is similar to the synaesthesia diagnostics above25 except that it elicits colours for graphemes (rather than personifications). Participants (n = 26 OS; n = 88 controls) first had the opportunity to self-report grapheme-colour synaesthesia given the question " Do numbers or letters have colour associations (i.e. which you've been aware of before now)?; Yes, No". Participants responding NO are classified as non-synaesthetes and are not tested further (following standard testing protocols3,22). Participants responding YES specify whether they experience colours for numbers, letters or both, and in the subsequent consistency test they are shown whichever graphemes they reported. In consistency testing, participants pair each grapheme with a colour, using an interactive colour-picker (see Fig. 1, right panel). Graphemes are each shown twice in a block-randomised design, and test-scores are an indication of the distance in colour space between each presentation of the same grapheme (e.g., the colour-distance between the two presentations of A). Smaller scores represent smaller distances, hence greater consistency-over-time. Scores are averaged across all trials and standardised; following validated methods3,33, synaesthetes were diagnosed as those scoring within the recognised synaesthetic window (i.e., ≤1.4334, where low scores indicate the high consistency typical of synaesthesia).

Order of experimental tests

Tests were presented in the following order: Autism screening [Part 1], SOSQ, Object-personification [Part 1], grapheme-personification synaesthesia test, grapheme-colour synaesthesia test, Autism screening [Part 2], Object-personification [Part 2].

Results

Links between objectum sexuality and autistic traits

In this section, we ask whether OS individuals show higher autistic traits compared to controls. All analyses here and throughout are two-tailed. In our first analysis, a 2 × 5 ANOVA contrasting group (OS vs. controls) and AQ factor (Social Skills, Attention switching, Attention-to-detail, Communication, Imagination) showed a main effect of group in that OS individuals possessed overall stronger autistic traits than controls (F(1,112) = 50.33, p < 0.001, ηp2 = 0.31; see Fig. 2). In addition we found a main effect of AQ factor (F(4,448) = 35.55, p < 0.001, ηp2 = 0.24) as well as an interaction between group and factor (F(4,448) = 6.96, p < 0.001, ηp2 = 0.06). Exploring this interaction further showed that OS participants scored higher than controls in every AQ factor (all corrected ps < 0.05) but particularly so in the social skills factor as indicated by its 'very large' effect size ( d = 1.5534,35 all other effect sizes were 'medium' ( d ≥ 0.5) to 'large' ( d ≥ 0.8); see Supplementary Information Table S1).

Mean AQ scores for OS and control participants. Higher scores represent more autistic-like traits (i.e., poor social skills, attention switching, communication, imagination; good attention to detail). Error bars show standard errors of the means (SEMs). Asterisks indicate corrected significance at *p < 0.05; **p < 0.01; ***p < 0.001.

The prevalence of autism in objectum sexuality

In addition to heightened AQ scores, 13 out of 34 OS participants (38.24%) but none of our 88 controls reported having an official diagnosis of autism, and this difference was significant (χ ²(1) = 33.75, p < 0.001, 95% CI [0.22, 0.56]). OS individuals also had significantly more diagnoses of autism compared to published epidemiological data from the general population9 (1.47%; χ ²(1) = 30.60, p  < 0.001, 95% CI [0.20, 0.55]). Note that all chi-square analyses here and throughout the manuscript are performed with the more conservative Yates continuity correction where expected cell counts fall below five observations.

Given our online methodology, we were not able to perform independent clinical autism assessments. We therefore ran additional analyses showing that even when we use more conservative methods for classifying participants as autistic, our results remain the same. Our first additional analysis classified participants as autistic only if they satisfy two criteria: 1) they self-reported a formal diagnosis of autism (as above) AND 2) they gave further spontaneous information about their diagnosis via our optional text-box (e.g., their age at diagnosis). Following this new autism classification, we continued to find significantly higher rates of autism in our OS group (8 out of 34; i.e., 23.53%) compared to our control group (0 out of 88; χ ²(1) = 18.49, p < 0.001, 95% CI [0.10, 0.42]). This more conservative rate of autism in OS was again significantly higher than published epidemiological data from the general population9 (1.47%; χ ²(1) = 14.39, p < 0.001, 95% CI [0.08, 0.40]). Finally, we also analysed our AQ data and classified participants as autistic only if they scored above the recognised indicative threshold for autism (i.e. ≥ 32 points). Once again we found a significant group difference: there were 10 out of 34 OS participants classified as autistic (29.41%), compared to 2 out of 88 controls (2.27%; χ ²(1) = 17.42, p < 0.001, 95% CI [0.12, 0.46]). Moreover, rates of autism in the OS group were once again significantly higher than published epidemiological data from the general population (1.47%; χ ²(1) = 20.60, p = < 0.001, 95% CI [0.13, 0.46]). In summary, we find higher rates of autism/ autistic traits for OS individuals in all analyses.

Links between objectum sexuality and synaesthesia

We first asked whether OS participants experience synaesthesia-like personalities from objects. We therefore analysed scores from the Multisense Test for Object-personification synaesthesia. During this test, OS participants had rated the personality of their object-partner while controls rated the personality of their 'most-loved or favourite object'. Both groups were then given a surprise retest. We calculated the consistency of object-personalities by regressing participants' responses for their first set of personality descriptions against their second (retest) set of descriptions. OS participants were significantly more consistent over time ( t(109) = 3.63, p < 0.001, d  = 0.92, 95% CI [9.13, 31.11]) in their object-personality descriptions (M = 69.5%, SD = 18.5%) compared to controls (M = 49.4%, SD = 24.8%) supporting the hypothesis that OS feelings might stem from what can be recognised as object-personification synaesthesia.

Next, we investigated whether OS was related to a more generalized synaesthetic phenotype, by looking at whether OS individuals also have other variants of synaesthesia. Here we diagnosed grapheme-personification synaesthesia and grapheme-colour synaesthesia, using recognised protocols and previously validated thresholds22,31,33. We found higher rates of both types of synaesthesia in our OS group.

Considering first grapheme-personification synaesthesia, we found higher rates of synaesthesia in the OS group compared to controls (although only in gender scores, see Table 1; we remind the reader that it is possible to diagnose grapheme-personification synaesthesia either for grapheme genders (e.g., letter A is female) or for grapheme personalities (e.g., letter A is shy)).

Table 1 Rates of grapheme-personification synaesthesia in OS and Control groups.

Since seven of our OS participants left our study before taking this (grapheme-personification) synaesthesia test, we repeated our analysis with the conservative assumption that all were non-synaesthetes and this still resulted in a strong trend for a higher prevalence of confirmed grapheme-personification synaesthesia for gender associations in the OS group compared to controls, χ ²(1) = 3.618, p = 0.057, 95% CI [−0.004, 0.30].

In addition to the above finding, we also found significantly elevated rates of grapheme-colour synaesthesia, which was 14 times higher in OS individuals (15.4% i.e., 4 out of 26) compared to controls (1.1% i.e., 1 out of 88 controls; χ ²(1) = 6.62, p = 0.01, 95% CI [0.02, 0.35]) and 11 times higher than the known population-wide baseline (of 1.4%3; χ ²(1) = 25.34, p < 0.001, 95% CI [0.04, 0.34]). Since eight of our OS participants left our study before taking the grapheme-colour synaesthesia test, we repeated our analysis with the conservative assumption that all were non-synaesthetes and our findings remained significant (χ ²(1) = 4.60, p = 0.032, 95% CI [0.01, 0.27]). Finally, we also considered whether OS individuals might have synaesthesia simply because they may also have autism, given that synaesthesia and autism are co-morbid6,12,13. But rates of grapheme-colour synaesthesia were still significantly higher than controls even when considering only OS individuals who did not have autism (14.29%; 3 out of 21; χ ²(1) = 4.99, p = 0.025, 95% CI [0.01, 0.36]).

Further above we have seen that OS individuals give personality traits for their object-partners that are consistent over time. We point out that the high consistency in reports of personalities described by OS individuals for their object-partners were not simply some heightened ability to remember personality traits: OS individuals were no more consistent than controls when attributing personalities to letters or numbers (revealed by a lack of group differences in prevalence for personality ratings during the grapheme-personification test). This suggests that OS individuals are not better memorisers of personalities in general, but tend to have genuine object-personification synaesthesia, as well as elevated rates of both grapheme-personification synaesthesia (for genders only) and grapheme-colour synaesthesia.

Discussion

To date, only one other study7 has addressed objectum sexuality (OS) and our research is the first to take an empirical behavioural approach in studying this form of sexual orientation. We recruited a group of individuals who self-identify as OS and a group of non-OS controls. Our study was motivated by the hypothesis that autism and synaesthesia (i.e., object-personification synaesthesia) might play a role in OS, at least for some OS individuals.

We found a number of significant relationships between OS and synaesthesia. Firstly, we found that the romantic affections of OS individuals towards objects do appear to be driven, at least in part, by object-personification synaesthesia. This was revealed by the fact that OS individuals do tend to sense personality traits in their object-partners, and that these show the synaesthetic hallmark of consistency-over-time (i.e. the OS group were significantly more consistent compared to controls when assigning personalities to inanimate objects). We propose that synaesthetic personalities and genders might increase the anthropomorphic qualities of inanimate objects which could facilitate the development of intimate and romantic feelings over time. Finally, OS was also associated with a broader synaesthetic phenotype in showing significantly elevated rates of two other types of synaesthesia, grapheme-personification synaesthesia and grapheme-colour synaesthesia.

We found too that rates of diagnosed autism were over 30 times higher in OS individuals than otherwise expected (or 14 times higher even with our most conservative estimate). Differences were most associated with the Social Skills sub-scale of the AQ (finding social situations difficult or unenjoyable, with a preference for objects over humans in one AQ question). Poor inter-human relationships may be relevant to why OS individuals develop relationships with objects although it is unclear whether poorer social skills might be a contributing factor towards OS or indeed a consequence. For instance, objectum sexuals experience considerable social stigma attached to their orientation2 which could affect social skills through an avoidance of interactions with other people. Relatedly, anthropomorphizing has been suggested to be a compensatory mechanism when individuals experience increased levels of loneliness36 and autistic individuals report higher ratings of loneliness compared to controls37. Other autistic traits might also facilitate feelings of intimacy with objects: a strong need for routine might be fulfilled more easily in relationships with objects rather than people, while higher attention-to-detail and a tendency for special interests could promote heightened focus on, or appreciation for particular objects7. Finally, synaesthetic personifications may further reinforce this attention since objects with positive synaesthetic personalities are even known to bias eye-movements for synaesthetes15. Nonetheless, we point out that just over one third of OS individuals did not report a diagnosis of autism and did not score above the AQ threshold (although a number of these scored closely). It is therefore possible that autism is not a necessary prerequisite for OS in all cases. Nevertheless, our current data suggests that OS, autism, and synaesthesia are linked at multiple levels and future research could focus on delineating the precise nature of how autism and synaesthesia interact in OS.

An important methodological consideration is the fact that our OS participants were recruited from forums online. We took this approach because it would have been difficult to achieve in-person testing given that OS is rare, internationally distributed, and without any regular real-world meeting place (as far as we are aware). More importantly, our participants were reassured by the protection of anonymity, meaning that in-person testing would inevitably have reduced sample size. Importantly, one might wish to argue that recruiting from online platforms could disproportionally attract people with social difficulties (and thereby elevate AQ scores). However, we point out that the OS group scored higher than controls across all factors of the AQ (Social skills, Attention-switching, Attention-to-detail, Communication, and Imagination) suggesting that our results are not skewed by the social traits of people drawn to online forums. Relatedly, one might wish to argue that rates of autism may be a priori higher on such forums, but we point out that rates of diagnosed autism in OS individuals was almost 40%, a prevalence that is hard to explain away as the result of our online recruitment methods.

In addition to the above consideration, we note that our online methodology did not allow for us to perform clinical diagnoses of autism; we therefore took participants' reports of autism at face-value. Nevertheless, we were careful to ask about " formal" diagnoses, and we replicated our findings on a sub-set of participants whose formal diagnoses were backed-up with substantive details (i.e., when their diagnoses had taken place). We further replicated using AQ scores (based on the autism threshold of ≥3219). Given these conservative approaches, we are confident our classifications of autism are accurate, and we also point out that our findings are replicated by our analysis of autism rates in the cohort tested by Marsh7 (see Introduction). Finally, we address one last concern, that AQ scores in OS participants could be circular, given that one question in the AQ (out of 50) could potentially define OS (i.e., the reverse-coded "I find myself drawn more strongly to people than to things"). If we remove this question from our AQ analysis we still observe the same pattern of results (i.e. OS individuals still score significantly higher on the Social skills factor of the AQ with a large effect size; and 10 OS individuals compared to 2 controls still score above the diagnostic threshold ≥32 on the AQ overall; see Supplementary Information Table S2). Nonetheless, even aside from the 'literal' question described above, it could be argued that high scores on the social factor of the AQ might simply reflect the social challenges of identifying as OS. Importantly however, OS individuals were elevated across all sub-scales of the AQ. We are therefore confident that our results speak to rates of autism, rather than being a circular finding about OS per se.

Our data speak to biological38, psychological39,40 and philosophical41 models of sexuality or romantic love. We inform biological theories by showing that certain sexual orientations can be found at higher rates within recognised neurodevelopmental conditions with known genetic traits10,42 and specific neurological profiles43,44 independent from the sexual orientation itself. Fifty-three percent of our OS cohort was characterised as having either synaesthesia and/or autism (from diagnosis or elevated AQ scores, with a further 9% scoring close to threshold), placing these well-understood neurodevelopmental conditions firmly at an intersection with this sexual orientation. Our data also support one very recent suggestion45 that autism might dictate sexual preference to some extent, and suggest the need for raised awareness among medical practitioners to support and promote inclusion for autistic people regarding orientation. Our data also speak to models of synaesthesia showing synergistic outcomes when synaesthesia and autism co-occur within individuals6 and they speak to the study of anthropomorphism36 by validating the use of detailed personality questionnaires46 for non-human targets. We suggest that this methodology might be further exploited to ask whether personality profiles for objects in OS (or indeed in general anthropomorphism) are random or ordered. For example, our methods could test whether object-personalities reflect the personality traits of those humans making judgements - as would be predicted if object personifications arise from mechanisms within self-other judgements16,47. Finally, our data address psychological39 and philosophical41 models of romantic love which have traditionally been defined around personhood (i.e., a feeling of pleasure derived from an attraction towards another person). Our findings suggest, crucially, that personification rather than personhood may be the necessary pre-requisite for romantic love to arise.

Our study is the first behavioural treatment of OS in the scientific literature. Although inquiry into OS has gained little traction in modern science, wider understanding would be particularly beneficial given that objectum sexuals are often marginalised for their orientation2. In summary, we have shown links between OS, synaesthesia and autism, and propose that increased anthropomorphizing in OS may sometimes occur as a result of differences in social cognition and other autism-driven traits as well as object-personification synaesthesia.

Data availability

The data supporting this study are available via the UK Data Service.

Acknowledgements

The research leading to these results received funding from the European Research Council under the European Union's Seventh Framework Programme (FP/2007-2013) / ERC Grant Agreement n. [617678] and the UK Economic and Social Research Council, ESRC (grant number ES/K006215/1). We are grateful to Erika Eiffel for help recruiting participants and for providing valuable feedback on our tests.

Author information

Authors and Affiliations

1. School of Psychology, Pevensey Building, University of Sussex, Brighton, BN1 9QJ, UK

Julia Simner & James E. A. Hughes

2. Centre for Cognitive Neuroscience, College of Health and Life Sciences, Brunel University, London, Uxbridge, UB8 3PN, UK

Noam Sagiv

Contributions

J.S. conceived the study and wrote the paper. J.S. and J.E.A.H. designed the tests. J.E.A.H. set up the tests, analysed the data and co-wrote the paper. J.S. and J.E.A.H. recruited participants and interpreted data. N.S. provided intellectual contributions.

Corresponding author

Correspondence to Julia Simner.

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The authors declare no competing interests.

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Simner, J., Hughes, J.E.A. & Sagiv, N. Objectum sexuality: A sexual orientation linked with autism and synaesthesia. Sci Rep 9, 19874 (2019). https://doi.org/10.1038/s41598-019-56449-0
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DOI: https://doi.org/10.1038/s41598-019-56449-0

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Access to community-based HIV services among transgender women in Cambodia: findings from a national survey - International Journal for Equity in Health

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Background Globally, the prevalence of HIV among transgender women is more than 40 times higher than the prevalence in the general reproductive-age adults. They also face intersecting barriers to health, social, and legal services due to their hidden and stigmatized nature. Despite the particular needs, data regarding the access to services among transgender populations is scant globally. This study aims to identify characteristics of transgender women in Cambodia that may determine their accessibility to community-based HIV services. Methods In the National Biological and Behavioral Survey 2016, a structured questionnaire was used for face-to-face interviews with 1375 sexually active transgender women recruited from the capital city and 12 other provinces using the Respondent-Driven Sampling method. Weighted multivariate regression analysis was conducted to explore factors associated with access to community-based HIV services. Results The mean age of the participants was 25.8 years (SD = 7.1), and 45.0% reported having received at least one community-based HIV service in the past three months. Compared to participants who reported not having been reached by any community-based HIV programs, participants who reported having been reached by the programs were significantly more likely to reside in an urban setting (AOR = 1.41, 95% CI = 1.01–1.96), to have used gender-affirming hormones (AOR = 1.50, 95% CI = 1.17–1.92), to have been tested for HIV in the past six months (AOR = 7.42, 95% CI = 5.78–9.53), and to have been arrested by police or other authorities because of their transgender identity (AOR = 1.55, 95% CI = 1.03–2.33). Participants who reported having been reached by community-based HIV programs were significantly less likely to report being in a receptive role (AOR = 0.34, 95% CI = 0.15–0.82), to use condoms consistently with non-commercial male partners (AOR = 0.72, 95% CI = 0.55–0.94), and to perceive that their co-workers were not supportive regarding their transgender identity (AOR = 0.57, 95% CI = 0.44–0.98). Conclusions Despite the extensive expansion of community-based HIV programs, less than half of transgender women in this national survey had access to the services. Innovative strategies and culturally sensitive interventions should be put in place to reach and respond to the needs of sub-groups of transgender women who are less likely to be reached by the existing traditional approaches.

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“The liberation of LGBTQ+ will also liberate heterosexuals”: heterosexual feminist women's participation in solidarity-based collective action for LGBTQ+ rights

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“The liberation of LGBTQ+ will also liberate heterosexuals”: heterosexual feminist women's participation in solidarity-based collective action for LGBTQ+ rights

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=256579

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“I’m Not as Gay as Some Other Queer People”: Exploring Bi + Men’s Perceptions of Masculinity and Sexual Identity

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“I’m Not as Gay as Some Other Queer People”: Exploring Bi + Men’s Perceptions of Masculinity and Sexual Identity

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=369589

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“I guess the trans identity goes with other minority identities”: An intersectional exploration of the experiences of trans and non-binary parents living in the UK

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“I guess the trans identity goes with other minority identities”: An intersectional exploration of the experiences of trans and non-binary parents living in the UK

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=336523

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“I feel more masculine having sex with a woman than being fucked by a man”: masculinity and bisexual men’s experiences of sex with women and men

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“I feel more masculine having sex with a woman than being fucked by a man”: masculinity and bisexual men’s experiences of sex with women and men

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=361066

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‘It is still coming from the centre and coming out’: the material conditions adding to over-bureaucratised patient and public involvement for commissioning health and care in England

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‘It is still coming from the centre and coming out’: the material conditions adding to over-bureaucratised patient and public involvement for commissioning health and care in England

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https://elements.sussex.ac.uk/viewobject.html?cid=1&id=307195

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"It takes a man to put me on the bottom": gay men's experiences of masculinity and anal intercourse

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"It takes a man to put me on the bottom": gay men's experiences of masculinity and anal intercourse

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"I don't want to be seen as a screaming queen": an interpretative phenomenological analysis of gay men's masculine identities

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"I don't want to be seen as a screaming queen": an interpretative phenomenological analysis of gay men's masculine identities

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"I carry so much anger and that is not good for my health", the mental health impact of current gender-affirming healthcare pathways on transgender adults in England

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"I carry so much anger and that is not good for my health", the mental health impact of current gender-affirming healthcare pathways on transgender adults in England

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“I Carry So Much Anger, and That Is Not Good for My Health” - Bulletin of Applied Transgender Studies

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This study aimed to explore the mental health impact of current gender-affirming healthcare (GAHC) pathways on transgender people in England. Trans participants (experts by experience) were recruited through purposive sampling and took part in qualitative semi-structured interviews between October 2021 and January 2022. The data generated were analysed and coded using a thematic framework analysis. Sixteen trans individuals participated. The majority were white, transfeminine, and reported a disability and/or neurodivergence. Four key themes reflecting the mental health impact of GAHC pathways were identified: (1) anticipated or experienced discrimination, (2) long waiting times for treatment, (3) socio-geographic disparities, and (4) the role of psychotherapy and peer support. The mixed and inequitable provision of GAHC contributes to trans minority stress and has a substantial negative impact on the mental health of trans individuals, with participants describing healthcare avoidance, anxiety, depression, hopelessness, suicidality, anger, and chronic stress-related physical disability. Early access through primary care services to hormone replacement therapy (HRT), voice coaching, laser hair removal, and fertility preservation is likely to improve the mental health of trans individuals, alongside trans-affirmative or trans-led psychotherapy and peer support.

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Currently advising research/policy at Stonewall

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Research on LGBTQ+ people and dispute resolution - a scoping review of publicly available resources for trans and non-binary people in the 27 countries in EU and in the UK)

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Engineering and Informatics, Life Sciences, Mathematical and Physical Sciences, Psychology, Brighton and Sussex Medical School (BSMS)

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Research and conference presentations on the rights of LGBTIQ+ children and young people, including a focus on sexual orientation and gender identity in a new project on dance and the law.

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Nuno Ferreira, Maria Federica Moscati, Senthorun Raj

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1. Queer(ing) Judgments
Nuno Ferreira, Maria Federica Moscati and Senthorun Raj

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Research into the lived experiences of TGNB student teachers in university training and on placement in schools.

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American Studies; Art History; Language Studies;

Drama, Theatre and Performance; English Language and Linguistics; English Literature and Creative Writing; Film Studies; History; Liberal Arts; Media, Journalism and Cultural Studies; Media Production and Filmmaking; Music; Philosophy

Link to MAH Board

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Education and Social Work, Global Studies, Law, Politics, and Sociology

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Accounting and Finance, Strategy and Marketing, Economics, Management, and SPRU

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Digital Intimacies and LGBT+ Youth: Celebration, Equity and Safety

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Digital Intimacies and LGBT+ Youth: Celebration, Equity and Safety

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The original report is by Rachel Thomson (University of Sussex), Sara Bragg (UCL Institute of Education) and Kate O’Riordan (University of Sussex) with Khalid Asaleh, Rosie Gahnstrom and Ester McGeeney. This summary was prepared for Brook by Lisa Hallgarten.

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The elusive bisexual: social categorization and lexico-semantic change

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The elusive bisexual: social categorization and lexico-semantic change

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Author

Lynne Murphy

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Beyond hagiography: new books on gay and lesbian life writing

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Beyond hagiography: new books on gay and lesbian life writing

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Author

Margaretta Jolly

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=156324

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Coming Out of the Coming Out Story: Writing Queer Lives

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Coming Out of the Coming Out Story: Writing Queer Lives

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Author

Margaretta Jolly

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=156591

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Queer Masculinity: The Representation of John Paul Pitoc's Body in Trick

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Queer Masculinity: The Representation of John Paul Pitoc's Body in Trick

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Author

Niall Richardson

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=157646

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The Queer Performance of Tilda Swinton in Derek Jarman’s Edward II: Gay Male Misogyny Reconsidered

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The Queer Performance of Tilda Swinton in Derek Jarman’s Edward II: Gay Male Misogyny Reconsidered

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Author

Niall Richardson

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=151921

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The queer activity of extreme male bodybuilding: gender dissidence, auto-eroticism and hysteria

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The queer activity of extreme male bodybuilding: gender dissidence, auto-eroticism and hysteria

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Author

Niall Richardson

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Queering a gay cliché: the rough trade/sugar daddy relationship in Derek Jarman's 'Caravaggio'

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Queering a gay cliché: the rough trade/sugar daddy relationship in Derek Jarman's 'Caravaggio'

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Author

Niall Richardson

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Three revolutionary years: The impact of the counter culture on the development of the gay liberation movement in Britain

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Three revolutionary years: The impact of the counter culture on the development of the gay liberation movement in Britain

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Author

Lucy Robinson

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Gay men and the left in post-war Britain: How the personal got political

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Gay men and the left in post-war Britain: How the personal got political

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Author

Lucy Robinson

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The Queer Cinema of Derek Jarman: Critical and Cultural Readings

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The Queer Cinema of Derek Jarman: Critical and Cultural Readings

# data[].attributes.body
Author

Niall Richardson

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Effeminophobia, Misogyny and Queer Friendship: The Cultural Themes of Channel 4's Playing It Straight

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Effeminophobia, Misogyny and Queer Friendship: The Cultural Themes of Channel 4's Playing It Straight

# data[].attributes.body
Author

Niall Richardson

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=163909

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Perversity to match the curtains: Queering the life story with Grayson Perry

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Perversity to match the curtains: Queering the life story with Grayson Perry

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Author

Margaretta Jolly

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‘Stay Still So We Can See Who You Are’: Anxiety and Bisexual Activity in the Contemporary Femme Fatale Film

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‘Stay Still So We Can See Who You Are’: Anxiety and Bisexual Activity in the Contemporary Femme Fatale Film

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Author

Katherine Farrimond

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=172270

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‘Stay Still So We Can See Who You Are’: Anxiety and Bisexual Activity in the Contemporary Femme Fatale Film

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Within the huge proliferation of femme fatale figures in Western cinema of the past two decades, one of the most striking patterns is the frequency of femme fatale characters who seduce women as we…

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Author

Lucy Robinson

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Sanctuaries for social outsiders: a queer archive of feelings in songs by the Smiths

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Sanctuaries for social outsiders: a queer archive of feelings in songs by the Smiths

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Author

Mimi Haddon

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‘To whom do our bodies belong?’ Being queer in Chinese DV documentary

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‘To whom do our bodies belong?’ Being queer in Chinese DV documentary

# data[].attributes.body
Author

Lucy Robinson

# data[].attributes.body
Author

Lucy Robinson

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Queering the grammar school boy: class, sexuality and authenticity in the works of Colin MacInnes and Ray Gosling

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Queering the grammar school boy: class, sexuality and authenticity in the works of Colin MacInnes and Ray Gosling

# data[].attributes.body
Author

Lucy Robinson

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Killing Off the Lesbians A Symbolic Annihilation on Film and Television

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Killing Off the Lesbians A Symbolic Annihilation on Film and Television

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Authors

Liz Millward

Janice Dodd

Irene Fubara-Manuel

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Marco: A Levantine queer encounter in London

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Marco: A Levantine queer encounter in London

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Author

Feras Alkabani

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The contemporary femme fatale: gender, genre and American cinema

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The contemporary femme fatale: gender, genre and American cinema

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Author

Katherine Farrimond

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‘Whether you are gay or straight, I don’t like to see effeminate dancing’: effeminophobia in performance-level ballroom dance

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‘Whether you are gay or straight, I don’t like to see effeminate dancing’: effeminophobia in performance-level ballroom dance

# data[].attributes.body
Author

Niall Richardson

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=180842

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Encountering the Niobe’s Children: Vernon Lee’s Queer Formalism and the Empathy of Sculpture

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Encountering the Niobe’s Children: Vernon Lee’s Queer Formalism and the Empathy of Sculpture

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Author

Francesco Ventrella

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=187070

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Encountering the Niobe’s Children: Vernon Lee’s Queer Formalism and the Empathy of Sculpture

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The materiality of sculpture was essential to Vernon Lee’s psychological theory of aesthetics based on the beholder’s physical responses. Through collaboration with her lover Clementina Anstruther-Thomson, Lee developed a theory of embodiment based on…

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Trois femmes cherchent la quadrature du cercle chromatique vers 1800-1930 / Three women squaring the color circle between ca. 1800 and 1930

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Trois femmes cherchent la quadrature du cercle chromatique vers 1800-1930 / Three women squaring the color circle between ca. 1800 and 1930

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Author

Alexandra Loske

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=189684

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Desire under conflict: The potential for queer in Hoda Barakat’s The Stone of Laughter

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Desire under conflict: The potential for queer in Hoda Barakat’s The Stone of Laughter

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Author

Feras Alkabani

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=190966

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Desire under conflict: The potential for queer in Hoda Barakat’s The Stone of Laughter

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This article examines Hoda Barakat’s original rendition of gender and sexual otherness in The Stone of Laughter (1990), the first Arabic novel with a queer protagonist, Khalil. The analysis sheds l…

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Author

Lucy Robinson

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=188131

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Thoughts on Pride: No Coal Dug

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Pride tells the story of a group of London lesbian and gay activists who offer their support to the striking miners in Dulais, South Wales. This article reflexively uncovers the layers through which the story of LGSM has been remembered, forgotten, and re-remembered through its personal and political connections.

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Ageing Predators and Asexual Old Queens: Challenging Stereotypes of Cross-Generational Gay Relationships in Beginners and Gerontophilia

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Ageing Predators and Asexual Old Queens: Challenging Stereotypes of Cross-Generational Gay Relationships in Beginners and Gerontophilia

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Author

Niall Richardson

https://elements.sussex.ac.uk/viewobject.html?cid=1&id=303646

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Ageing Predators and Asexual Old Queens: Challenging Stereotypes of Cross-Generational Gay Relationships in Beginners and Gerontophilia

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There are two dominant stereotypes of gay male ageing in Western media. The first is the sexual predator who secures brief relations with much younger men often through monetary exchange or other forms of coercion. The second is the stereotype of the asexual...