In recent decades there has been a shift in how the relationship between a trans identity and psychiatric disorders is perceived: from a trans identity as part of a psychiatric disorder (such as schizophrenia), to trans identity as a separate phenomenon disconnected from psychiatric disorders in modern understandings (ICD 11).

Regarding the prevalence of mental health conditions in adults with a trans identity or who are questioning their gender, a recent study shows that affective problems (anxiety and depression) are more common compared to the general population (Dhejne et al., 2016). The occurrence of psychological disorders, bipolar disorders and eating disorders is comparable to the general population.

A follow-up study throughout a gender affirming process found heightened scores on anxiety and depression before this process, but significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility after starting gender affirming care. Furthermore, the psychopathological parameters scores resembled those of a general population after hormone therapy was initiated (Heylens et al., 2014).

Suicidal ideation and self-harm in trans people is shown to be alarmingly high, with suïcidal ideation from 37% to 83% (McNeil et al. 2017), in contrast with 9.2% for the general population (Nock et al. 2008). The same trend is found for suicidal attempts, with numbers from 9.8% up to 44% (Miller et al., 2015), which are much higher than 2.7% for the general population (Nock et al., 2008). Unfortunately, also numbers regarding death by suicide are higher among transgender persons in comparison with the general population (Wiepjes et al, 2020). This suicide risk in trans people seems to occur during every stage of transitioning, but seems to decrease in time especially in trans women (Wiepjes et al. 2020). It is important to have specific attention for suicide risk in the counseling of this population and in providing suicide prevention programs.

Several studies have shown how the mental health of trans people is clearly linked with experiences with violence and discrimination, and a general lack of social acceptance and support. Experiences of victimisation, internal minority stress, problems with self-acceptance, anxiety preceding disclosure to others as well as the perceived inability or struggle to come out, concerns about negative evaluations of trespassing gender binary classifications, and lack of parental support and acceptance, are all shown to be directly linked with suicidal ideation and self-harm (McNeil, Ellis, & Eccles, 2017; Miller, Esposito-Smythers, & Leichtweis, 2015).

A trans woman sitting on a therapist couch and looking upset
Photo: The Gender Spectrum Collection

Studies focusing on young people show similar trends with stigmatizing interactions such as discrimination, negative comments in social interactions, and bullying resulting in higher odds of psychopathology. Another study showed how the absence of important peer relationships was the strongest predictor for behavioral and emotional problems. On the other hand, family attachments, connectedness at school, meaningful friendships, care and support resulted in 5x less risk of psychological problems (Veale et al., 2017; Watson et al., 2019; de Vries et al., 2014). Better understanding these minority stressors and resiliency factors can improve health professional’s ability to collaboratively develop goals for addressing transgender and non-binary people’s treatment needs.

It is however advisable to take into account differential diagnostics that in rare cases identifying as male, female or non-binary may be part of a psychiatric disorder. The distinction from a trans identity can be made based on the presence of other psychiatric symptoms such as delusions and hallucinations, disorganized speech and the like. It is also rare that a trans identity can be described in the context of a morpho dysphoric disorder: there is, for example, the persistent belief that genitalia are dirty and must be removed. In these cases, there is usually no reporting of general dissatisfaction with the assigned gender and identification with the associated gender role.

The existence of psychiatric problems should not be used as an exclusion criteria for accessing gender affirming care. Oftentimes, these issues are perceived as something ‘to heal from’ before being granted access to gender affirming treatments or surgeries. Gender affirming care and psychotherapy can support the trans person’s mental health to a large extent, and not receiving gender affirming care can indeed contribute negatively to their mental health. For specific mental health issues, additional psychological support can be recommended. Partner and family therapy may also be indicated, when wished for.

In a recent review, Murad et al. (2020) found improvements in gender dysphoria, psychological functioning and comorbidities, lower suicide rates, higher sexual satisfaction and, overall, improvement in the quality of life. Also, in this “after-transition” phase psycho-social support can be useful for a number of trans people, for example due to loss of a relationship, work or social contacts, or due to difficult life challenges and lack of social support or acceptance.

Although studied to a limited extent, it has clearly been shown that non-invasive treatment (psychotherapeutic, medicinal) for trans identities gender dysphoria has little to no influence on the incongruity between the assigned gender and the gender identity. Put a different way, conversion practices to change the gender identity of trans persons, which is outlawed in Malta​, is ineffective and unethical.

References:

  • de Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704. https://doi.org/10.1542/peds.2013-2958​
  • Dhejne C, Van Vlerken R, Heylens G, Arcelus J. Mental health and gender dysphoria: a review of the literature. Int Rev Psychiatry . 2016; 28: pp. 44-57.
  • Heylens G, Elaut E, Kreukels BPC et al. Psychiatric characteristics in transsexual individuals: multicentre study in four European countries. Br J Psychiatry . 2014; 204: pp. 151–156
  • ​Heylens, G., Verroken, C., De Cock, S., T’Sjoen, G., & De Cuypere, G. (2014). Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder. The Journal of Sexual Medicine, 11(1), 119-126. doi:10.1111/jsm.12363
  • McNeil, J., Ellis, S. J., & Eccles, F. J. R. (2017). Suicide in trans populations: A systematic review of prevalence and correlates. Psychology of Sexual Orientation and Gender Diversity, 4(3), 341-353. doi:10.1037/sgd0000235
  • Miller, A. B., Esposito-Smythers, C., & Leichtweis, R. N. (2015). Role of Social Support in Adolescent Suicidal Ideation and Suicide Attempts. Journal of Adolescent Health, 56(3), 286-292. doi:https://doi.org/10.1016/j.jadohealth.2014.10.265
  • Motmans J, de Biolley I, Debunne S. Transgender life in Belgium: Mapping the social and legal situation of transgender people 2009. Brussels, Institute for the equality of women and men.
  • Murad MH, Elamin MB., Garcia MZ et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology , 2020; 72: pp. 214-231.
  • ​Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30(1), 133-154. doi:10.1093/epirev/mxn002
  • Veale, J. F., Peter, T., Travers, R., & Saewyc, E. M. (2017). Enacted Stigma, Mental Health, and Protective Factors Among Transgender Youth in Canada. Transgend Health, 2(1), 207-216. doi:10.1089/trgh.2017.0031
  • Watson, R. J., Veale, J. F., Gordon, A. R., Clark, B. A., & Saewyc, E. M. (2019). Risk and protective factors for transgender youths’ substance use. Preventive medicine reports, 15, 100905. doi:10.1016/j.pmedr.2019.100905​
  • Wiepjes, C. M., den Heijer, M., Bremmer, M. A., Nota, N. M., de Blok, C. J. M., Coumou, B. J. G., & Steensma, T. D. (2020). Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study (1972–2017). Acta Psychiatrica Scandinavica, 141(6), 486-491. doi:https://doi.org/10.1111/acps.13164
  • World Health Organisation. (2018). International Classification of Diseases 11th Revision. Genf: World Health Organisation. https://icd.who.int/