Research roundup: The impact of stigma on the mental health status of transgender individuals

This issue highlights research into the impact of stigma on the psychosocial health and well-being of transgender youth and adults.

Research has found that individuals who identify as lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ) are at a greater risk of mental health concerns than their heterosexual peers (Cochran & Mays, 2000, 2005, Oswalt & Wyatt, 2011). 

Sexual orientation or gender identity of these individuals does not appear to automatically put them at risk of mental health issues. Familial, peer and community reactions can result in sexual stigma, discrimination and victimization that has been shown to impact mental health outcomes. The impact of these noted stressors is intensified for individuals who identify as transgender. These stressors not only have a negative impact on mental health but also create a barrier to mental health care utilization.

The following studies examined the mental health outcomes and resilience factors of transgender individuals as a result of the associated stigma, discrimination and victimization of their minority sexual orientation status. These studies also examined the differential experiences of these variables based on demographic factors such as age, race/ethnicity and gender, with particular attention paid to gender non-conformity and experiences of victimization. 

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.

Shipherd, J.C., Maguen, S., Skidmore, W.C., Abramovitz, S.M. (2011). Potentially Traumatic Events in a Transgender Sample: Frequency and associated symptoms. Traumatology, 17(2) 56-67. DOI: 10.1177/1534765610395614

The authors conducted a cross-sectional study of 97 transgender participants, between the ages of 20 and 72 years old, who had been classified as male at birth. Participants were asked to complete the Traumatic Life Events Questionnaire (TLEQ) to measure trauma exposure and assess a range of potentially traumatic events, PTSD Checklist Civilian version (PCL-C) to assess PTSD symptoms, the Center for Epidemiologic Studies- Depression Scale to assess symptoms of depression, and the Short Form-12 (SF-12) to assess general physical and mental health functioning. Those that rated any event category as experienced due to their transgender status were placed in the Bias group (42 percent), otherwise participants were placed in the Non-bias group. Furthermore, the sample was divided into two groups; More Time Dressed (50 percent of time or more spent dressed consistent with gender identity) or Less Time Dressed (less than 50 percent of time dressed consistent with identity). 

They found a 98 percent trauma exposure rate, with 90.7 percent of the sample population reportedly experiencing multiple potentially traumatic events. The More Time Dressed group indicated significantly more exposure to trauma than the Less Time Dressed group. However this difference was not associated with bias-related events. 

Modest symptoms of PTSD were found, with More Time Dressed group reporting higher levels. No group differences were found between the Bias and Non-bias participants. Those that reported exposure to potentially traumatic events endorsed clinically elevated symptoms of depression, again the More Dressed Time group were found to be higher on this scale, but Bias did not result in group differences. 

Practical Implications

Participants endorsed a rate of trauma (98 percent) that significantly exceeds the national rates suggesting a great likelihood of trauma exposure in the transgender population and a need for careful clinical assessment. Transgender individuals face much stigma and those who spent more time dressed consistently with their gender identity indicated clinically significant symptoms of depression and PTSD. 

Those individuals trying to find appropriate and comfortable expression of their gender identity may be at greater risk for traumatic events, a consideration psychologists should keep in mind during clinical work. 

Grossman, A.H., D’Augelli, A.R., Frank, J.A. (2011). Aspects of Psychological Resilience among Transgender Youth. Journal of LGBT Youth, 8(2) 103-115. DOI: 10.1080/19361653.2011.541347

This study examined a model of the aspects of psychological resilience among 55 transgender youth between the ages of 15 and 21, most of whom experienced psychological and social stresses associated with their minority gender identity and nonconformity. Of the 55 transgender youth, 31 of the youth were male-to-female (MTF) and 24 female-to-male (FTM) participants. 

The examined variables included self-esteem, a sense of personal mastery, perceived social support, and emotion-oriented coping. Additionally, the study explored developmental risks associated with society’s gender scripts and the elevated awareness of sexual and gender identities during late childhood and adolescence that could affect the mental health status of these individuals. 

Participants responded to interview questions related to sexual and gender orientation developmental milestones, provided ratings of their parents’ initial and current reaction to their identities and behaviors, and recalled the number of experiences with verbal, physical, and or sexual abuse by parents and peers. Participants also completed a battery of standard mental health measures.

The resilience model predicted 40-55 percent of the variance in psychological resilience relating to depression, trauma symptoms, mental health symptoms, and internalizing and externalizing problems. Results indicated higher self-esteem, a higher sense of personal mastery, and greater perceived social support, predicted positive mental health outcomes. 

Contrastingly, emotion-oriented coping predicted negative mental health outcomes. In regards to the development of gender identities all of the participants reported they “felt different from others” around the age of 8. Almost all of the FTM youth were called “tomboys” and the MTF youth were called “sissy” and were then told to stop acting as such by their parents. 

Congruent with previous research the more gender nonconforming the youth were, the more parental verbal and physical abuse they experienced. In regards to victimization; 71 percent of FTM and 87 percent of MTF youth reported past verbal abuse, 17 percent of FTM and 36 percent of MTF youth reported past physical abuse, and 16 percent of MTF youth reported past sexual abuse. 

Practical Implications

Transgender youth face significant amounts of discrimination and abuse, beginning in their homes. Psychologists working with such youth will need to engage with families to increase support and acceptance, when possible, and ensure the youths’ safety. The development of interventions that are focused on designing strategies for these families to support their transgender youth is key in nurturing the mental health of these youth.  

Additionally, psychologists will want to promote self-esteem, personal mastery, and social support to assist transgender youth in achieving positive realities. Task-oriented coping strategies appear more effective than emotion-oriented coping in assisting transgender youth adapt and manage their stress. 

Clements-Nolle, K., Marx, R., Katz, M. (2008). Attempted Suicide Among Transgender Persons. Journal of Homosexuality, 51(3) 53-69. DOI: 10.1300/J082v51n03_04

Lesbian, gay, and bisexual individuals have been found to be more likely to attempt suicide than their heterosexual peers, in part due to experiences of discrimination and victimization. Although studies examining suicide attempts in transgender individuals are limited researchers hypothesize a higher prevalence of suicidal behaviors due to the associated societal oppression. 

This study explored the independent predictors of attempted suicide among 329 MTF and 123 FTM transgender individuals. This study examined not only well known risk factors inclusive of substance abuse, physical and mental abuse, and depression, and potential mediators of suicide risk such as self-esteem but also discrimination and victimization. 

This cross-sectional study found that a history of attempted suicide was significantly higher among transgender individuals who were white, less than 25 years of age, recently unemployed, and had been incarcerated. Attempted suicide was also significantly associated with depression, low self-esteem score, history of alcohol and drug treatment, forced sex or rape, verbal gender victimization, gender discrimination, and physical gender victimization. 

Practical Implications

The findings of this study are congruent with findings of studies examining suicidal risk factors among LGB youth. Psychologists serving sexual minority youth need to provide counseling, suicide assessment, and relevant community referrals to gender questioning youth. Screening for known risks factors such as substance abuse, depression, and history of forced sex, but also specifically gender discrimination and physical victimization, may facilitate faster identification of those most at risk for attempting suicide. 

Beyond direct service provision to these youth, psychologists may also wish to develop interventions to increase familial and societal acceptance of this stigmatized population. Peer-based outreach interventions could aid in reaching youth that are hidden due to feared ostracism. Community awareness campaigns in addition to legislation focused on the discrimination and hate crimes against transgender youth may also help in the prevention of suicide among transgender individuals.  

The American Psychological Association Council of Representatives adopted Guidelines for Psychological Practice with Transgender and Gender Non-conforming People during the recent Annual Convention in Toronto. For more information on the noted guidelines see: Guidelines for psychological practice with transgender and gender nonconforming people.