Transgender-based disparities in suicidality: A population-based study of key predictions from four theoretical models

Gender Minority Stressors, Hopelessness, and Their Associations with Internalizing and Externalizing Mental Health Outcomes in a Hungarian Trans Adult Sample

Although distal (i.e., discrimination, victimization, rejection, and nonaffirmation) and proximal (i.e., internalized transphobia, negative expectations, and identity nondisclosure) gender minority stressors are associated with internalizing (i.e., depression, anxiety, suicidality) and externalizing (i.e., substance use) mental health outcomes of trans individuals, how they are related to two distinct types of outcomes differs. General psychological processes (i.e., hopelessness) could explain the mechanisms behind the minority stressors-mental health association. Accordingly, this study aimed to test the complete gender minority stress model and the direct and indirect effects of minority stressors via hopelessness on mental health outcomes in trans individuals. Data were collected online from a convenience sample of 205 trans adults (18-74 years; M = 29.49, SD = 10.24), 72 (35.1%) of whom were trans men, 52 (25.4%) were trans women, and 81 (39.5%) were non-binary individuals. Results from structural equation modeling showed that distal stressors directly predicted mental health outcomes, except for depression. Internalized transphobia and negative expectations had positive indirect effects on depression, anxiety, and past-year and lifetime suicidality via hopelessness. Identity nondisclosure had negative indirect effects on depression, anxiety, and past-year suicidality through hopelessness. For substance use, hopelessness was not a significant mediator. Still, identity nondisclosure mediated distal stressors-substance use link. Findings suggest that hopelessness is a significant contributor to internalizing symptoms of trans individuals, making it a target for interventions to improve the mental health of trans people. The ameliorative impact of identity nondisclosure on both types of mental health outcomes should be considered and examined in further studies.

The Association Between Sexual Violence and Suicidal Ideation Among Transgender Women and the Role of Gender-Affirming Healthcare Providers in Seven Urban Areas in the United States, 2019 to 2020

Transgender women are disproportionately affected by sexual violence and corresponding mental health sequelae; however, many do not access healthcare due to experiences with transphobia. This analysis evaluated the association between sexual violence and suicidal ideation and the moderating effect of having a healthcare provider (HCP) with whom transgender women were comfortable discussing gender-related issues ("gender-affirming HCP"). We analyzed cross-sectional data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance among Transgender Women (NHBS-Trans). Transgender women were recruited using respondent-driven sampling from seven urban areas from 2019 to 2020 and participated in an HIV biobehavioral survey. This analysis was restricted to transgender women who visited a HCP in the past 12 months ("healthcare-seeking transgender women" [HSTW]) (N = 1,489). Log-linked Poisson regression models provided adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to estimate the association between sexual violence and suicidal ideation in the past 12 months. The interaction between sexual violence and having a gender-affirming HCP was statistically significant (p-value = .034). Among 1,489 HSTW, 225 (15.1%) experienced sexual violence and 261 (17.5%) reported suicidal ideation; 1,203 (80.8%) reported having a gender-affirming HCP. Sexual violence was associated with suicidal ideation (aPR = 2.65, 95% CI [2.08, 3.38]); the association was notably higher among those who did not have a gender-affirming HCP (aPR = 3.61, [2.17, 6.02]) than among those who did (aPR = 1.87, [1.48, 2.37]). Eliminating transphobia and promoting trauma- and violence-informed approaches in healthcare are necessary for sexual violence and suicide prevention among HSTW.

Heightened vigilance and its associations with suicidal ideation and suicide attempt among 285 Korean transgender and nonbinary adults: Effect modification by connectedness to the LGBTQ+ community

INTRODUCTION

Anti-transgender stigma presents threats of discrimination to transgender and nonbinary (TGNB) individuals, prompting them to stay vigilant. Using a longitudinal data of 285 South Korean TGNB adults, we examined vigilance and its associations with suicidal ideation and suicide attempt and explored the protective role of connectedness to the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community.

METHODS

Data were collected in October 2021 (baseline) and October 2022 (follow-up). Vigilance was measured using the 4-item Heightened Vigilance Scale at baseline. At follow-up, 12-month suicidal ideation and suicide attempt, and connectedness to the LGBTQ+ community were measured.

RESULTS

Having heightened levels of vigilance was associated with increased prevalence of suicidal ideation (Prevalence Ratio [PR]: 1.33, 95% Confidence Interval [CI]: 1.09-1.62) and suicide attempt (PR: 2.18, 95% CI: 1.23-3.86), after adjusting for covariates including anti-transgender discrimination experiences and lifetime suicidality at baseline. When stratified by connectedness to the LGBTQ+ community, the associations between vigilance and suicidality remained statistically significant among those with low connectedness whereas no statistically significant association was observed among those with high connectedness.

CONCLUSION

The study provides empirical evidence for policies and interventions that ensure safety of TGNB individuals from discrimination and promote connectedness to the LGBTQ+ community to reduce the suicide risk among TGNB individuals.

Dissociative Experiences Among Transgender Women: A Phenomenological Study

There is little published research on dissociative experiences among transgender people, and none from an in-depth qualitative perspective. In-depth, open-ended interviews (N = 7, 6 trans women, 1 trans man) were conducted to explore how dissociation is experienced (particularly among trans women) and its possible relation to negative emotions. There were several similarities across the dissociative experiences described by participants: six felt themselves disconnected from their body as a whole (in contrast to feeling disconnected to a specific body part), and from the world around them and/or themselves. Four acted out different personalities, and five felt emotionally numb when they were dissociating. Six participants described that their dissociation lessened after they started hormone therapy. Respondents tended to distinguish between dysphoric and dissociative experiences: dysphoric phenomena were more clearly distressful while dissociative ones were more emotionally numb.

Protective and Risk Factors for Suicidal Ideation and Behavior Among Sexual Minority Women in the United States: A Cross-Sectional Study

Purpose: The purpose of this study was to understand the factors associated with suicidal ideation and behavior and serious suicidal ideation and behavior among sexual minority women (SMW), including resilience, discrimination, mental health, and sociodemographic characteristics. Methods: Web-based surveys were conducted with SMW from across the United States during January-February, 2022 using psychometric valid tools. Bivariate, hierarchical regression, and logistic regression analyses were used to analyze the data. Results: Of 497 participants, 70% were identified as bisexual and 30% as lesbian. The mean scores for anxiety, depression, and stress were significantly higher among bisexual women compared to their lesbian counterparts (p < 0.05). The proportion of serious suicidal ideation and behavior was higher among bisexual women compared to lesbian women (53.9% vs. 41.2%, p = 0.012). Conversely, the mean scores of resilience were lower among bisexual women compared to lesbian women (139.7 ± 33.4 vs. 147.5 ± 33.6, p = 0.024). Lesbian women had nearly 57.4% lower odds of having serious suicidal ideation and behavior as compared to bisexual women (adjusted odds ratio = 0.426; p = 0.023). Experiencing anxiety, depression, victimization distress, and family discrimination distress were positively associated with serious suicidal ideation and behavior, whereas personal resilience and family cohesion were negatively associated with serious suicidal ideation and behavior. Conclusions: Tackling structural inequities such as racism and homophobia remains vital to improving the mental health of SMW. Interventions to strengthen social and familial supports may be particularly impactful, especially at the family level.

Minority stress and mental health in European transgender and gender diverse people: A systematic review of quantitative studies

The current study aimed at systematically reviewing evidence on the relationships between gender minority stress and mental health outcomes among European transgender and gender diverse (TGD) individuals. A systematic search was conducted in PsycINFO, PubMED, Scopus, and Google Scholar. It was based on Boolean operators to combine terms related to minority stress, TGD identities, and mental health. Thirty studies were identified as eligible. The results confirmed that gender minority stress factors are significantly related with mental health problems among European TGD individuals. Distal stressors were identified as strongly associated with poorer mental health, with gender-related discrimination emerging as the most documented risk factor. The significant role of proximal stressors was also highlighted, with some mediation analyses detecting an indirect effect on mental health. However, identity concealment appeared unrelated to mental health outcomes. Resilience-promoting factors buffering the impact of stressors were also identified, including self-esteem, pride, transitioning, and social support. Conversely, data on community connectedness as a source of resilience were inconclusive. The studies reviewed have several limitations, including lack of longitudinal designs, sampling bias, variability in measurement methods, and unaccounted ethnic variables. Research and clinical recommendations in this field are reported.

Social Support and the Association Between Certain Forms of Violence and Harassment and Suicidal Ideation Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Violence and harassment toward transgender women are associated with suicidal thoughts and behaviors, and social support might moderate such association. This analysis explored the association between certain forms of violence and harassment and suicidal ideation and moderation by social support. Better understanding of these associations could guide mental health services and structural interventions appropriate to lived experiences of transgender women. This cross-sectional analysis used data from CDC's National HIV Behavioral Surveillance Among Transgender Women. During 2019-2020, transgender women were recruited via respondent-driven sampling from seven urban areas in the United States for an HIV biobehavioral survey. The association between experiencing certain forms of violence and harassment (i.e., gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation was measured using adjusted prevalence ratios and 95% CIs generated from log-linked Poisson regression models controlling for respondent-driven sampling design and confounders. To examine moderation, the extents of social support from family, friends, and significant others were assessed for interaction with certain forms of violence and harassment; if p interaction was <0.05, stratified adjusted prevalence ratios were presented. Among 1,608 transgender women, 59.7% experienced certain forms of violence and harassment and 17.7% reported suicidal ideation during the past 12 months; 75.2% reported high social support from significant others, 69.4% from friends, and 46.8% from family. Experiencing certain forms of violence and harassment and having low-moderate social support from any source was associated with higher prevalence of suicidal ideation. Social support from family moderated the association between experiencing certain forms of violence and harassment and suicidal ideation (p interaction = 0.01); however, even in the presence of high family social support, experiencing certain forms of violence and harassment was associated with higher prevalence of suicidal ideation. Social support did not completely moderate the positive association between experiencing violence and harassment and suicidal ideation. Further understanding of the social support dynamics of transgender women might improve the quality and use of social support. Policymakers and health care workers should work closely with transgender women communities to reduce the prevalence of violence, harassment, and suicide by implementing integrated, holistic, and transinclusive approaches.

Kept in the Closet: Structural Stigma and the Timing of Sexual Minority Developmental Milestones Across 28 European Countries

Structural stigma's role in lesbian, gay, and bisexual (LGB) people's attainment of identity development milestones remains unknown. In a sample of 111,498 LGB people (ages 15 to 65+) living across 28 European countries, associations were investigated between structural stigma measured using an objective index of discriminatory country-level laws and policies affecting LGB people and the timing and pacing of LGB self-awareness, coming out, and closet duration, and subgroup differences in these associations. On average, self-awareness occurred at age 14.8 years old (SD = 5.1), coming out occurred at 18.5 years old (SD = 5.7), and the closet was 3.9 years long (SD = 4.9); thereby highlighting adolescence as a key period for sexual identity development and disclosure. Greater structural stigma was associated with higher odds of never coming out, later age of coming out, and longer closet duration. Gender identity, transgender identity, and sexual identity moderated associations between structural stigma and these developmental milestones. Reducing structural stigma can plausibly promote sexual identity development among LGB populations, especially during adolescence when identity related milestones are often attained.

A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours

INTRODUCTION

Gender dysphoria (GD) is characterized by the incongruence between one's experienced and expressed gender and assigned-sex-at-birth; it is associated with clinically significant distress. In recent years, the number of young patients diagnosed with GD has increased considerably. Recent studies reported that GD adolescents present behavioural and emotional problems and internalizing problems. Furthermore, this population shows a prevalence of psychiatric symptoms, like depression and anxiety. Several studies showed high rates of suicidal and non-suicidal self-injurious thoughts and behaviour in GD adolescents. To increase understanding of overall mental health status and potential risks of young people with GD, this systematic review focused on risk of suicide and self-harm gestures.

METHODS

We followed the PRISMA 2020 statement, collecting empirical studies from four electronic databases, i.e., PubMed, Scopus, PsycINFO, and Web of Science.

RESULTS

Twenty-one studies on GD and gender nonconforming identity, suicidality, and self-harm in adolescents and young adults met inclusion criteria. Results showed that GD adolescents have more suicidal ideation, life-threatening behaviour, self-injurious thoughts or self-harm than their cisgender peers. Assessment methods were heterogeneous.

CONCLUSION

A standardised assessment is needed. Understanding the mental health status of transgender young people could help develop and provide effective clinical pathways and interventions.

Changes in Health Insurance During COVID-19 Among a U.S. National Cohort of Cisgender Gay and Bisexual Men and Transgender Individuals

The extant data suggest that LGBT communities were disproportionately impacted by the economic ramifications of the pandemic and were more likely to report being uninsured throughout the first two years of the pandemic. Additionally, these groups are at heightened vulnerability for several health conditions that require insurance to manage or prevent. Thus, there is a need to assess changes in pandemic-era insurance coverage among these populations. This study uses data collected as part of the Together 5,000 study, a U.S. national, internet-based cohort study of cisgender men, trans men, and trans women who have sex with men. We analyze insurance data across three different assessments between 2019 and 2021, exploring changes in insurance coverage and type. Among our sample, 6.4% lost their insurance in 2020 because of the pandemic. Insurance loss was associated with living in a state that had not expanded Medicaid, race/ethnicity, employment status, and income. Among those who lost their insurance in early 2020, most (59.2%) reported gaining insurance by 2021, with those living in non-expanded states less likely to gain insurance. Finally, those who were uninsured prior to the pandemic were less likely to report gaining insurance by 2021, when compared to those uninsured as a result of the pandemic. This suggests that there are uninsured cisgender gay and bisexual men and transgender individuals that continue to go unreached by policies to assuage uninsurance. Further policy intervention is needed to address uninsurance among LGBT individuals, which has important implications for addressing health disparities among these populations.

The Impact of Sexual Violence on Quality of Life and Mental Wellbeing in Transgender and Gender-Diverse Adolescents and Young Adults: A Mixed-Methods Approach

Transgender (trans) and gender-diverse (GD) adolescents and young adults have remained largely invisible in health research. Previous research shows worse outcomes in health indicators for trans and GD people, compared to cisgender controls. Research on the impact of sexual violence focuses on mainly cisgender female adult victims. This study assessed the impact of sexual violence on the quality of life (QoL) and mental wellbeing (GHQ-12) among trans and GD adolescents and young adults, while taking into account the possible role of gender nonconformity in sexual violence and mental wellbeing. An online, anonymous survey and interviews/focus groups were conducted between October 2021 and May 2022 in Belgium. Multiple analyses of covariance (ANCOVAs) were used to assess the associations between sexual violence, mental wellbeing, and gender nonconformity, while controlling for different background variables (gender identity, sexual orientation, age, economic vulnerability, etc.). The interviews and focus groups were used to validate associations between variables that were hypothesized as important. The quantitative sample consisted of 110 respondents between 15 and 25 years old, with 30 trans respondents (27.3%) and 80 GD respondents (72.7%). A total of 73.6% reported experiences with sexual violence over the past two years (n = 81). The mean QoL score was 5.3/10, and the mean GHQ-12 score was 6.6/12. Sexual violence was not significantly associated with QoL (p = 0.157) and only marginally significantly associated with GHQ-12 (p = 0.05). Changing one's physical appearance to conform to gender norms, out of fear of getting attacked, discriminated against, or harassed was significantly associated with QoL (p = 0.009) and GHQ-12 (p = 0.041). The association between sexual violence and changing one's physical appearance to conform to gender norms was analyzed, to assess a possible mediation effect of sexual violence on mental wellbeing. No significant association was found (p = 0.261). However, the interviews suggest that sexual violence is associated with changing one's physical appearance, but this association is not limited to only trans and GD victims of sexual violence. Non-victims also adjust their appearance, out of fear of future sexual victimization. Together with the high proportion of sexual violence, as well as the lower average QoL and higher average GHQ-12 scores among trans and GD adolescents and young adults, compared to general population statistics, this highlights the need for policy makers to create more inclusive environments.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

Disparities in health condition diagnoses among aging transgender and cisgender medicare beneficiaries, 2008-2017

Introduction

The objective of this research is to provide national estimates of the prevalence of health condition diagnoses among age-entitled transgender and cisgender Medicare beneficiaries. Quantification of the health burden across sex assigned at birth and gender can inform prevention, research, and allocation of funding for modifiable risk factors.

Methods

Using 2009-2017 Medicare fee-for-service data, we implemented an algorithm that leverages diagnosis, procedure, and pharmacy claims to identify age-entitled transgender Medicare beneficiaries and stratify the sample by inferred gender: trans feminine and nonbinary (TFN), trans masculine and nonbinary (TMN), and unclassified. We selected a 5% random sample of cisgender individuals for comparison. We descriptively analyzed (means and frequencies) demographic characteristics (age, race/ethnicity, US census region, months of enrollment) and used chi-square and t-tests to determine between- (transgender vs. cisgender) and within-group gender differences (e.g., TMN, TFN, unclassified) difference in demographics (p<0.05). We then used logistic regression to estimate and examine within- and between-group gender differences in the predicted probability of 25 health conditions, controlling for age, race/ethnicity, enrollment length, and census region.

Results

The analytic sample included 9,975 transgender (TFN n=4,198; TMN n=2,762; unclassified n=3,015) and 2,961,636 cisgender (male n=1,294,690, female n=1,666,946) beneficiaries. The majority of the transgender and cisgender samples were between the ages of 65 and 69 and White, non-Hispanic. The largest proportion of transgender and cisgender beneficiaries were from the South. On average, transgender individuals had more months of enrollment than cisgender individuals. In adjusted models, aging TFN or TMN Medicare beneficiaries had the highest probability of each of the 25 health diagnoses studied relative to cisgender males or females. TFN beneficiaries had the highest burden of health diagnoses relative to all other groups.

Discussion

These findings document disparities in key health condition diagnoses among transgender Medicare beneficiaries relative to cisgender individuals. Future application of these methods will enable the study of rare and anatomy-specific conditions among hard-to-reach aging transgender populations and inform interventions and policies to address documented disparities.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Training in LGBTQ-affirmative cognitive behavioral therapy: A randomized controlled trial across LGBTQ community centers

OBJECTIVES

This randomized controlled trial examined whether an 11-week synchronous (i.e., real-time) online training in lesbian, gay, bisexual, transgender, queer, and other sexual or gender diverse (LGBTQ)-affirmative cognitive behavioral therapy (CBT) could lead to increased uptake of this practice at LGBTQ community centers across 20 U.S. states and internationally.

METHOD

A total of 121 mental health providers (Mage = 37.74; 78.5% LGBTQ; 60.3% non-Hispanic/Latinx White) were randomized to receive the 11-week training either immediately (n = 61) or after a 4-month wait (n = 60). At baseline and 4 and 8 months after baseline, participants self-reported their LGBTQ-affirmative competency, cultural humility, and knowledge of the minority stress theory and practice skills underlying LGBTQ-affirmative CBT. To objectively assess uptake of LGBTQ-affirmative CBT, participants demonstrated, through simulated practice, how they would respond to two video-based clinical vignettes.

RESULTS

Compared to wait-list, participants in the immediate training condition reported greater improvements in self-reported cultural competence (d = 1.24), minority stress knowledge (d = 0.78), LGBTQ-affirmative CBT knowledge (d = 0.78), and LGBTQ-affirmative CBT skills familiarity (d = 0.91) and use (d = 0.96); effects persisted 8 months postbaseline. Cultural humility showed no significant difference by condition (d = 0.07). In objectively coded assessments of simulated practice, participants in the training condition demonstrated greater uptake of LGBTQ-affirmative practice skills (d = 0.82).

CONCLUSIONS

Findings preliminarily suggest that mental health providers can be trained to deliver LGBTQ-affirmative CBT using the low-cost, efficient reach of online training. This training can help disseminate evidence-based mental health care to LGBTQ individuals and support its implementation across practice settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).