By Katherine Schreiber
Individuals who identify as transgender tend to experience higher rates of mental health issues than the general population. While approximately 6.7 percent of the general U.S. population suffers from depression and 18 percent grapple with some iteration of an anxiety disorder, nearly half of all individuals who identify as transgender experience these issues. What's more, over 41 percent of trans men and women are estimated to have attempted suicide — a rate that's nearly nine times as high as the rate of cisgender Americans.
What underlies this astonishingly elevated rate of mental health issues? According to a study published in the July 2016 edition of The Lancet offers significant evidence that the "distress and impairment, considered essential characteristics of mental disorders" among transgender individuals primarily arises in response to the discrimination, stigma, lack of acceptance, and abuse they face on an unfortunately regular basis.
Shame and Stigma
Psychologists have been documenting the effect that stigma, rejection, discrimination, and abuse have on mental and physical health for decades. As the American Psychological Association pointed out in its March 2016 report on the impact of discrimination, "for many adults, dealing with discrimination results in a state of heightened vigilance and changes in behavior, which in itself can trigger stress responses—that is, even the anticipation of discrimination is sufficient to cause people to become stressed."
They add that "adults who are LGBT who have experienced discrimination have average stress levels of 6.4, compared to 6.0 for LGBT adults overall." In addition to the fact that "among adults who are non-LGBT, stress levels are 5.5 for those who have experienced discrimination and 5.0 for non-LGBT adults overall."
Further research by Wendy Berry Mendes and colleagues at the University of California, San Francisco has unearthed discrimination's causative role in inclining those on it's receiving end to engage in risk-taking behaviors. Out of 91 subjects participating in an online discussion with confederates who offered them rejecting or encouraging feedback, those who were on the receiving end of rejecting feedback (i.e., "Someone's a little high on themselves" or "I can't tell where you're going with this...") were more likely to take risks in a subsequent card game with small amounts of money at stake.
Rejection also led to "greater cortisol increases, less efficient cardiac output, increased vascular resistance, and impaired memory recall — a pattern of physiological reactivity that, when experienced chronically and excessively, has been linked to accelerated 'brain aging,' cognitive decline, and early risk for Alzheimer’s disease," as the Association for Psychological Science reported.
Stigma can also directly affect health by encouraging ostracized individuals to avoid social encounters, shy away from healthcare professionals, reach for addictive substances to quell their anxiety and aloneness, or engage in (other) risk-taking behaviors, like unsafe sex.
Unfortunately, discrimination even by medical and mental health professionals is a common reality for many transgender individuals. A 2015 study published in the Milbank Quarterly found that out of 452 transgender people residing in Massachusetts, 65 percent reported being on the receiving end of discrimination in the context of a public accommodation (from hospitals and health centers to public transportation mechanisms and shopping centers) and 24 percent reported discrimination in a health care setting, which the researchers found to be linked with up to an "81 percent increased risk of adverse emotional and physical symptoms and a 2-fold to 3-fold increased risk of postponement of needed care when sick or injured and of preventive or routine health care."
Another survey, carried out by the National Center for Transgender Equality and the National Gay and Lesbian Taskforce, found that 50 percent of all transgender individuals "reported having to teach their medical providers about transgender care" while 19 percent said they had been "refused care due to their transgender or gender non-conforming status."
The consequences of a lack of acceptance and empathy in both medical and social settings can be catastrophic. "At the interpersonal and community levels," Simran Shaikh and colleagues write in the Journal of the International AIDS Society, "transgender populations often experience high levels of both perceived and internalized social stigma, social isolation, discrimination, and victimization. Extreme social exclusion and lack of acceptance of transgender populations in different settings diminish their self-esteem and ability to participate in social events. These situations often lead to symptomatic psychological distress, depression, anxiety and other mental health difficulties among this population. Social victimization may occasionally contribute to poor sexual health and unhealthy use of alcohol among this group."
Saikh et al. acknowledge that much of the distress transgender individuals experience while seeking medical help stems from the fact that most medical training excludes adequate education around transgender health matters: "as a result," Saikh et al. write, "health professionals lack the appropriate skills and competencies to provide tailored services to transgender populations."
Cadyn Cathers, a psychological assistant who specializes in working with transgender individuals and is also a faculty member at Antioch University, Los Angeles, understands this discrimination first hand. After he developed a skin infection on the portion of his arm from which a free flap of skin was taken to construct his penis during a nine-hour long gender-confirming surgery, he sought help from a dermatologist. The dermatologist insisted on seeing his genitals.
"She said 'I need to see your genitals.' I said, 'No, you don't. You just need to see where the infection is.' It became a half-hour discussion. Finally, I just said 'I'm out,' and left."
Later, when Cathers sought another doctor versed in treating skin grafts to ensure his wounds were healing properly, he says he had to go through approximately 30 clinics whose receptionists did not return his inquiries or flat-out rejected him. "I would get hung up on if I said I had gender-confirming surgery," Cathers recalls, "so I finally said I was 'in an accident' in order to be seen."
Cathers often ruminates over what might happen if he fell gravely ill and needed to see a specialist but was unable to locate one who was trans-friendly — or if he ever found himself in a situation where emergency medical services weren't aware he required different care due to his gender-confirming surgery. Not knowing how to handle a reconstructed urethra, for instance, they might bungle the job of inserting a catheter. ("Those who have had a phallus constructed may have a urethra that is placed through the phallus, or it may still be positioned under the phallus, at its base," explains the Gender Identity Research and Education Society.)
Another serious concern for transgender individuals is a high rate of homelessness (especially for youth) and unemployment due to guardians who won't tolerate gender non-conforming young adults and employers who discriminate against qualified candidates due to their dress or presentation. Though depriving a dependent under age 18 of shelter or food constitutes child abuse there is currently no federal law protecting transgender individuals from discrimination in the workplace.
Being Deprived of a Self
Rejection, discrimination, abuse, and other mistreatment of transgender individuals can impede their psychosocial and identity formation. There's a theory in Heinz Kohut's self psychology, Cathers explained to me, that you only develop a fully formed 'self' if three fundamental needs are met: Mirroring (a caregiver's accurate and consistent reflection of your emotional state), idealization (someone to look up to; a role model) and twinship (having someone who is 'like you,' that makes you feel you aren't alone in the world." Many trans people grow up lacking one or more of these crucial elements, Cathers added, which leaves them feeling isolated, unprotected, and much more vulnerable to life's inevitable stressors.
Cathers knew "there was something missing" from his body from an early age but it wasn't until he encountered transgender role models and others who could relate to his feelings in college that he began identifying as trans.
Many transgender individuals may attempt to come out earlier in their lives but, in the face of rejection or discomfort from someone they love and care about (say, a parent, or a close friend) feel shocked back into silence.
Von Scully, an ESL teacher and author of the blog Tra(n)velling Man, recalls feeling an onset of unbearable discomfort in his skin during puberty: "around age 14 I started to experience what people would call gender dysphoria — an immeasurable and indescribable feeling, almost like I was pushing out on my own skin, trying to get out, or like an itch that I could never scratch," Scully recalls. "I didn't know where it was coming from because I’d always been very comfortable with my body. But suddenly I felt wrong. My face felt masculine but the rest of my body didn't fit. I felt like a gollum stitched together."
When he was 16, Scully attempted to explain these sentiments to his mother, with whom he had always been incredibly close. "I said to her 'sometimes I feel like maybe I'm not a girl, maybe I'm a boy, too, and she got very upset," Scully says. "Her reaction was so emotional that I backed off and I repressed it.
News about violence towards transgender individuals can also dissuade individuals from identifying publicly as the gender they feel is truer to who they are. Aware of the shockingly high number of transgender individuals who were murdered because of their gender identity, Cathers held the belief during his early college years that "coming out pretty much meant I needed to be okay with dying. So it became a question of facing death but feeling alive or being a walking zombie that was dead inside."
Scully, too, felt a sense of deadness inside as he refrained from openly discussing his trans identity: "Part of me just stopped existing for quite a while because I didn’t have a choice in the matter. If I wanted peace and tranquility that wasn’t going to happen if I was going to be myself."
How Acceptance Helps
When someone who identifies as transgender is surrounded by a supportive community (teachers, friends, family, school, or work colleagues) their rates of mental health issues are markedly decreased. This is a testament to the power our environments (and those who populate them) have over our emotional wellness and risk for pathology.
A study published in the February 2016 edition of Pediatrics found that transgender youth whose families, friends, and teachers honored their desires to dress and socialize as the gender with which they identified "had only marginally higher anxiety symptoms" and "developmentally normative levels of depression."
Considering that previous research has confirmed emotional support's ability to reduce the stress experienced from discrimination it makes sense that acceptance from others helps salve the agony of feeling a dissonance between the gender society ascribes to you and the gender you feel you actually are.
Cathers and Scully say that the strength of their social support networks — including romantic partners, friends, and medical and mental health professionals — plus visible trans role models enabled them to feel comfortable outwardly identifying as transgender, and later undergoing gender-affirming surgeries.
"I spent five years figuring out what kind of man I wanted to be before I started to transition," Cathers says. "Once I began the process, it just felt good. I started being able to date, build more connections, and be more productive at work. There was this massive aliveness that happened." Cathers likens his transition to having recovered from a low grade cold: "When it finally goes away you suddenly realize wow, I’m functioning so much better now."
Scully, now 24, is currently on testosterone replacement therapy and had a double mastectomy in May of 2015. "I feel truly sexy for the first time," Scully says of his transition.
"I actually look in mirrors now. I go to the gym. And I no longer buy ugly, oversized clothing to hide my body. It's kind of like having a birthday every day. Each morning, when I wake up, I get the biggest present in the whole world. And I don't have to give it back."
Scully says that though it was a challenge for his mother at first, eventually she came to embrace her son for the man he truly was. "Once I’d told her I was really serious about hormones I think she trusted me to know what I was talking about. It wasn't just some idea that I had. She came with me to get my hormones for the first time. She was totally in it from there."
The Parent Trap
It was a challenge for mother Jennifer Campisi when her second child started saying they were transgender, but she states she has seen the mental health benefits of acceptance first hand. Her son, assigned female at birth, expressed sentiments suggesting that he identified more with the male gender as early as kindergarten: For starters, he preferred to play 'the dad' in games and was reluctant to wearing traditional 'girls'' clothes. Around age four, Campisi says E.J. — whose name was then "Eva" — started insisting his family and peers call him Jake or Adam. "We didn't know what to do," Campisi recalls, "the kid was asking the strangest questions, like, 'When I get older do I need to marry a boy?' or 'Do I have to get boobs?'" Campisi had already raised a daughter, E.J.'s older sister, who never asked questions and requests never cropped up. From age five, onwards, E.J. began wishing to become a boy on his birthdays and expressed that all he wanted for Christmas one year was to be the opposite gender.
Campisi and her husband began seeking help and eventually found GENECIS, a multidisciplinary outpatient program housed in Children's Health in Dallas's pediatric endocrinology clinic. Through GENECIS, E.J. — who is now 10 years old — receives comprehensive care in the form of puberty monitoring (and hormone therapy) as well as psychotherapy. Campisi and her husband are also involved in GENECIS's family counseling as well as a support network for parents of transgender children in the Dallas-Fort Worth area called that Campisi co-founded.
Campisi certainly had her own concerns prior to affirming E.J.'s gender and supporting his desire to dress and present as a boy. But it appears that just as much as her own acceptance helped her son, acceptance from others also helped her: "One of my biggest fears was, 'How am I going to explain this to people, what are they going to think?' It helped to surround myself with people who were accepting, who had known my kid for a while and saw what was going on. I also did a lot of reading and research, which helped me come around, as did meeting other families with kids who were happier after they'd transitioned."
Dr. Meredith Chapman, a Child & Adolescent Psychiatrist who works in the GENECIS program, stresses the importance of finding affirming communities, support networks, education, and awareness. "A common misconception is that transgender people are something new, or modern. People who defy the gender binary have been around for millennia, but the popular media is only beginning to acknowledge them here in America. What is new is that we have developed, and still are developing, language to address and acknowledge the experience of people who are transgender. The internet has been an enormous help in raising awareness, which can make it easier to talk about your experience and learn how to access appropriate interventions at earlier ages, but there's obviously still a long way to go."
"As we started meeting other parents who were going through the same process with their transgender child," Campisi says, "it reassured us that it was going to be okay — that he, E.J. would be okay if we supported him." Campisi says she hasn't stopped worrying about E.J.'s future—and it's unknown whether E.J. and other children like E.J. who are put on puberty blockers and cross-sex hormones will face medical complications from such treatments—but she has developed more faith that things will be alright: "We just have to keep educating people," she says. "I think that’s part of being visible, too. Because once people meet E.J., or other trans kids and families, they realize these people are normal. They have jobs, they go to school, they go to church."
Acceptance Goes Both Ways
Initial rejection combined with the agony of feeling as if one's body is somehow mismatched with the gender one feels inside can only be expected to cause negative moods. "Some people think the trans community is pretty angry," Cathers admits, "and I'm like, 'well, yea if you're living incongruently and in a society that doesn't accept you, you aren't going to be happy.'"
Scully understands this sentiment. But he's also aware that some requests for greater sensitivity can be perceived as overly militant. Hence Scully's emphasis on the importance of bringing forth more compassion from all parties involved. "A lot of the time the questions and wondering that come forward from cis people are absolutely innocent," he explains. "They're comfortable with their gender. They may not have ever felt that feeling inside of them where they want to rip their own skin off."
Trying as it may be, the more understanding we are when it comes to another person's gender, the better the outcome will be for everyone involved in the conversation. "There is no us versus them," Scully adds. "It's, I'm experiencing something this person isn’t. And that doesn't make one person more or less acceptable."