- Negative mental health outcomes are associated with a lack of access to gender-affirming care.
- Families, parents specifically, have reported fear, anxiety, and anger as a result of anti-trans legislation.
- Anti-trans legislation may also directly affect public perception of gender minorities.
- Behavioral health providers can assist individuals by exploring advocacy and activism strategies.
This post was written by Erica D. Marshall-Lee, Ph.D., ABPP, and Desiree G. Frain, Psy.D., on behalf of the Atlanta Behavioral Health Advocates.
Here I (Erica D. Marshall-Lee) am again stating that this is nothing new. My frustration, fear, and concern is a chronic condition that seems to be shared by many.
Infringing on individual agency and voice, anti-trans legislation was signed into Georgia state law on March 23, 2023. This law includes strict legislation preventing youth from receiving gender-affirming healthcare. The law goes into effect July 1, and adolescents who are already receiving gender-affirming healthcare will be permitted to continue. Otherwise, most transition-related surgeries and hormone therapies for youth are prohibited.
The likely mental health impact of this legislation on youths and families affected by these restrictions is vast. Anxiety, depression, and suicide have all been documented as mental health sequelae associated with a lack of access to gender-affirming care (American Medical Association [AMA], 2019).
The AMA indicated that individuals with gender dysphoria, which is a “marked incongruence between an individual’s experienced or expressed gender and the one they were assigned at birth” (American Psychiatric Association, 2013), without gender-affirming treatment, are two times as likely to face moderate to severe depression and four times more likely to encounter anxiety than those who have undergone these surgeries and treatments. Indeed, the AMA goes on to state that approximately one-third of transgender people experience a major depressive episode during their lifetime, 20.2 percent express suicidal behavior in a 30-day timeframe, and 7.9 percent are diagnosed with an anxiety disorder (AMA, 2019).
Kuper et al. (2022) reported that families, specifically parents, also reported fear, anxiety, and anger as a result of anti-trans legislation. The discrimination, bullying, stigma, and isolation that their children suffer negatively impact family and parental mental health outcomes (Abreu et al., 2021). As the mother of an African-descended male and grandmother of three, I know what it is like to fear for your child’s safety and mental well-being. It keeps you up at night and results in a chronic state of anxiety.
In some states, parents are faced with criminal prosecution if they support their children and pursue gender-affirming care. This is compounded by the fact that some children would rather be dead than go on living in their present state. Losing a child is a place no parent wants to find themselves, and the desperation, helplessness, and loss of agency resulting from these restrictions could prove to be devastating for these families. Indeed, lack of access to gender-affirming care has been found to be a strong predictor of suicide risk among transgender persons (AMA, 2019).
Not only does this legislation impact the mental health of families affected, but it may also directly affect the public’s perceptions of gender minorities, which further perpetuates a cycle of harm and bigotry that result in even more victimization and loss of protection for an already vulnerable population. One needs only look to recent policy changes to observe a salient example.
After 2016, the U.S. government decided to no longer follow guidance for protecting the rights of transgender students in schools, including recommendations for the use of preferred pronouns and allowing trans students to use bathrooms consistent with their gender identity. After this change, rates of perceived discrimination based on sexual or gender identity continued to rise from 44 percent to 55 percent (GLAAD, 2018).
The AMA and other medical organizations have stated that gender-affirming care is a medical necessity that can result in positive outcomes for adolescents and children in addition to adults (Hurt, 2023). Studies have found decreased rates of suicide attempts, with rates reduced from 30 percent pre-treatment to 8 percent post-treatment, as well as lower anxiety and depression (AMA, 2019).
Recently, integrated affirmative models of care for youth were found to result in fewer mental health challenges than traditionally experienced in transgender populations. Also of note, after receiving gender-affirming care, adolescents’ self-reported feelings of regret are extremely low (AMA, 2019).
It has been illustrated above that gender-affirming medical care typically has positive impacts on trans youth and adults. Naturally, it is concerning for mental health professionals to hear that access to these necessary services is becoming more restricted and prohibited. How do we, commissioned to do no harm, seek justice, and promote equity, proceed? We can start by 1) examining the data concerning the impact of these laws on transgender, gender nonconforming, and gender nonbinary (TNG) individuals and 2) investigating how we can best support and advocate on behalf of the communities we serve who are directly impacted by these events.
The question of mental health impact is not novel to researchers dedicated to investigating minority stress and structural stigma. In 2016, a study comparing TNG individuals in states with nondiscrimination laws and TNG individuals in states without such laws found that individuals in states without these protections reported higher levels of perceived stigma in their communities, which resulted in higher levels of anxiety and likelihood of having attempted suicide (Gleason et al., 2016).
Still, the literature is growing, as a disturbing number of new anti-trans policies are still being introduced. A recent study (Horne et al., 2022) found a similar connection between anti-LGBTQ legislation and anxiety, which the authors proposed leads to increased depression in this population.
What kind of response is appropriate for mental health professionals who support TNG individuals? First, it is necessary to consider how these policies and political movements may impact the clients we serve and interact with who are directly targeted. To take it a step further, I (Desiree G. Frain) challenge professionals to contend with the symptom-based status quo of mental health diagnosis and evaluation and consider how minority stress may prove a very rational explanation for experiences of anxiety, depression, and distress in TNG clients.
Alternative targets for treatment with these individuals may include supporting and coaching clients in joining supportive communities and discussing their concerns with social supports that may be ignorant of or complacent with the current political climate. Lastly, we may assist TNG individuals who wish to directly argue their rights in the face of injustice by exploring advocacy and activism strategies with them.
Abreu, R. L., Sostre, J. P., Gonzalez, K. A., Lockett, G. M., & Matsuno, E. (2021). “I am afraid for those kids who might find death preferable”: Parental figures’ reactions and coping strategies to bans on gender affirming care for transgender and gender diverse youth. Psychology of Sexual Orientation and Gender Diversity, 9(4), 500–510. https://doi.org/10.1037/sgd0000495
American Medical Association. (2019). Health insurance coverage for genderaffirming care of transgender patients. In American Medical Association. Retrieved April 5, 2023, from https://www.ama-assn.org/system/files/2019-03/transgender-coverage-issue-brief.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Horne, S. G., McGinley, M., Yel, N., & Maroney, M. R. (2022). The stench of bathroom bills and anti-transgender legislation: Anxiety and depression among transgender, nonbinary, and cisgender LGBQ people during a state referendum. Journal of Counseling Psychology, 69(1), 1–13. https://doi.org/10.1037/cou0000558
Hurt, E. (2023, March 23). Georgia’s ban on transgender care for minors becomes law. Axios. https://www.axios.com/local/atlanta/2023/03/21/georgia-transgender-minor-healthcare-bill-approve
GLAAD. (2018). Accelerating acceptance 2018. http://www.glaad.org/files/aa/Accelerating%20Acceptance%202018.pdf
Gleason, H., Livingston, N. A., Peters, M. M., Oost, K. M., Reely, E., & Cochran, B. N. (2016). Effects of state nondiscrimination laws on transgender and gender-nonconforming individuals’ perceived community stigma and mental health. Journal of Gay & Lesbian Mental Health. https://doi.org/10.1080/19359705.2016.1207582
Kuper, L. E., Cooper, M. B., & Mooney, M. A. (2022). Supporting and advocating for transgender and gender diverse youth and their families within the sociopolitical context of widespread discriminatory legislation and policies. Clinical Practice in Pediatric Psychology, 10(3), 336–345. https://doi-org.proxy.library.emory.edu/10.1037/cpp0000456