Transgender Mental Health: Gender Affirming Care and Support

According to the American Psychiatric Association, the term “transgender” refers to a person “whose sex assigned at birth (usually based on external genitalia) does not align with their gender identity (i.e., one’s psychological sense of their gender).” Gender identity does not always match up with someone’s sex assigned at birth, and even sex is not always as simple as some may think. Transgender individuals and others whose gender identities do not conform to societal standards may face health challenges, including mental illness and medical concerns. This article aims to educate on gender dysphoria, gender affirming care, and the potential health barriers that many transgender individuals, especially transgender youth, may face.

While some of the statistics and information in this article refer specifically to transgender people, many also apply to those who identify as gender non-conforming, non-binary, gender expansive, genderqueer, genderfluid, etc.

Gender Identity Basics and Clinical Language Updates

The outdated terminology that was used to describe this phenomenon was “gender identity disorder”. This is not a recognized condition, and is not used by researchers or clinicians. Updated terminology that can help explain gender identity challenges includes:

• Gender identity refers to an individual’s internal sense of gender.
• Gender incongruence is the state of having a gender identity that does not correspond to the sex assigned at birth.
• Gender dysphoria is the sense of distress that can happen when this incongruence occurs, often accompanied by a strong desire to fix it.

It’s important to understand that being transgender is not a disorder, nor is it classified among disorders by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition.

Transgender identity and what it can include

Transgender is an umbrella term with many lived experiences. Not all people experience it the same way, transition in the same way, or look the same way. Gender identity is your internal knowledge of gender, while gender expression is how a person expresses their gender on the outside. Some transgender folks may identify as “man” or “woman” and be referred to as “he/him”, “she/her”. Others may express themselves as neither a man nor a woman, or a combination of both, and refer to themselves as non-binary or genderqueer, with pronouns of “they/them”. 

How gender dysphoria can affect mental health

While many transgender and gender non-conforming people experience gender dysphoria, not every transgender person will have these feelings. There are mental health challenges associated with living with gender dysphoria, but it is not a mental illness in the same way as anxiety disorders, for instance. More than one study has found that transgender people tend to experience higher rates depression and other mental health conditions than cisgender (those who identify with their assigned sex at birth) or non-queer people as a result of their lived experiences with discrimination, a lack of acceptance, poverty, and even violence; all of these can take a toll on a person’s mental health. 

Transgender people may also experience mental illness due to a lack of general medical and mental health care, or because they cannot receive gender-affirming care. This is especially true for those with intersecting identities, such as transgender people of color and/or those who have a disability. People who are transgender and live with other mental health disorders may also face significant challenges, such as severe psychological distress, low self-esteem, suicidal ideation, and increased suicide rates due to a lack of care. Sometimes, members of the trans community may develop substance use disorder or engage in substance misuse as a means to cope with emotional distress.

Compounding these challenges is the fact that transgender people often face significant barriers to quality mental health care. Read on to find out more about LGBTQ+ mental health, including what can be done about this issue.

Risk factors for the mental health of transgender individuals

According to one study, there are various risk factors that may make a transgender person more likely to develop a mental illness. These include unemployment, low income, limited education, everyday discrimination, and violence. Marginalization, bullying, stereotypes, and being unhoused often also contribute to a higher rate of mental disorders, and all of these tend to be more common among transgender and gender non-conforming people. Again, each of these factors may be compounded in individuals who also face racism, ableism, xenophobia, and other forms of discrimination. These risk factors tend to be higher than they are in the general population and may explain why there seem to be more mental health issues among those with a transgender status.

Policy and barriers that impact mental health

In the United States and many other countries, these societal barriers are reinforced by state and local laws that deny pathways to care. Legislation can also involve high-profile pundits and politicians voicing negative stereotypes, bullying, and reinforcing outdated opinions on the transgender population as a whole. In addition to dealing with the challenges within their own lives and connections, this can add another layer of stress involving the safety and acceptance of their identity and communities. 

Those denied care may also be subjected to forms of conversion therapy, which, despite growing opposition, remains legal in a number of states.

Ongoing research within the transgender community

• Transgender people are six times more likely to experience a mood disorder or an anxiety disorder than those who are cisgender.
• “Sexual minority adults,” including all of those in the LGBTQIA+ community, are more likely to experience an eating disorder than cisgender, heterosexual individuals, which one study attributes to “the minority stress and discrimination experienced by these individuals.”
• Statistics from 2021 show that transgender adults are also more likely to be diagnosed with a substance use disorder than cisgender adults, as their lived experiences may make them turn to substances to cope with distress, as one article reports.
• Transgender people are more than four times more likely to be a victim of violent crime than cisgender people.
• According to the Trevor Project, fewer than 1 in 3 transgender and nonbinary young people say they find their home to be gender-affirming. This can contribute to significant distress in transgender children.
• Transgender individuals who can receive acute mental health care are more likely to experience marginalization during their experience, such as not having their gender recognized or pronouns respected. For this reason and others, many people push for professionals to offer informed gender-affirming medical care, such as gender-affirming hormones and gender-affirming surgery.
• The Center for American Progress reports that 28% of transgender survey respondents say they postponed or avoided seeking necessary medical care in the last year for fear of experiencing discrimination, which includes 22% transgender respondents of color.
• Young people who identify as transgender are three to four times more likely to engage in self-harming behavior.

Again, in addition to experiencing higher rates of mental illness than cisgender and non-queer people, transgender and gender non-conforming individuals also statistically face more obstacles to receiving medical and mental health care. Some of the most common barriers to care include the following. The following are some of the most common barriers to gender affirmation and transition-related care options

Some areas, such as smaller towns or rural areas, don’t have providers who can offer the specialized care that some transgender people may need—such as hormone therapy, gender affirming treatments, gender-affirming surgeries, or mental health care.

Transgender people in less populated areas may also struggle to find informed, empathetic therapists or psychiatrists who have experience in transgender issues, and may even face discrimination and/or harassment in healthcare settings for their mental health concerns.

Provider challenges with gender identity

According to one survey, one in three transgender respondents say they’ve had to “teach their doctor about transgender people in order to receive appropriate care”. Many care providers are uninformed about the needs and experiences of transgender people, or may even exhibit open disdain or hostility toward these individuals when they seek care for their mental health conditions. Transgender mental health and gender-diverse mental health information may not yet be widely known or acknowledged.

Many people, regardless of gender identity, aren’t able to receive the medical or mental health care they may need because of cost. This is especially true for transgender people. As of January 2022, “trans men and nonbinary or gender-nonconforming people earn 70 cents for every dollar the typical worker earns, while trans women earn 60 cents to that dollar,” which is slightly more than half of what the typical worker may earn. This can greatly impact transgender health resources like support groups and getting a psychiatric diagnosis and treatment from a mental health professional.

Transgender people are also more likely to experience unemployment and poverty than the rest of the US population. All of the above is especially true for those with intersecting identities, such as trans and gender non-conforming people of color.

Transgender people are 1.7 times more likely to experience intimate partner violence than cisgender people. Those who are in an abusive relationship may also face a restriction of resources, including financial resources. This can be particularly true for transgender youth who are dependent on an abusive caregiver. Situations like these can make it difficult or impossible for transgender individuals to receive the healthcare they may need.

Mental health resources for transgender people

As you can see from the statistics above, the barriers many transgender people face when it comes to seeking mental healthcare and other types of healthcare are complex, interconnected, and systemic.

Advocating for legislation that supports and empowers transgender people, fights discrimination, and broadens the availability of crucial gender affirmation care is one important way that those who are passionate about this issue can help. 

Another is to volunteer with and/or donate to organizations that support the mental health of transgender people.

Organizations that provide support:

• The National Queer and Trans Therapists of Color Network (NQTTCN), which fights for social justice for trans people of color in particular and helps such individuals find empathetic, affirming therapists.
• The Trevor Project, an organization dedicated to supporting LGBTQIA+ youth in particular through a crisis hotline, resources, and tools for finding community.
• The National Center for Transgender Equality is a social justice organization that advocates for legislation to defend and empower transgender people and offers advice and resources related to healthcare, insurance, legal aid, and more for transgender individuals.
• Trans Lifeline, an organization run by and for transgender people that offers a support lifeline, community, information about crucial resources, and more.

Gender affirmation in daily life and relationships

If you have a family member or friend who is gender non-conforming or transgender, understand that gender affirmation in daily life and relationships can be key in improving mental health markers across the board. You can also make an effort to support the transgender and gender non-conforming people in your life and community. Ways to do this include using the correct name, pronouns, and other identifiers related to gender identity for those around you, standing up against harassment, stereotypes, and bullying at school, in the workplace, and in social settings, and providing support and affirmation for queer youth in your life.  Family support and protective environments can mean the difference between fear and safety, and even between life and death for young people. 

Resources for transgender individuals seeking mental health care

If you identify as transgender or gender non-conforming, you can connect with the organizations above for support and resources for mental health care, mental health disorders, and other needs. You can also visit your local LGBTQIA+ community center or search for other community organizations and nonprofits in your area that specialize in the needs of queer individuals.

Signs you might need support now

Finding confidential and gender affirming support is important in any case, but if you notice that depressive symptoms or anxiety are interfering with daily function or relationships, then make seeking professional support a priority. If you are having suicidal thoughts, then reach out immediately, either to the crisis lifeline or to emergency services. 

Coping skills, identity affirmation, and supportive care

Resiliency factors that can impact LGBTQ health include medical transition options, community connection, and peer support. Supporting medical transition options such as gender affirming hormone therapy and hormone treatment, affirming mental health care, and surgical transition as matters of public health can be essential to protecting transgender loved ones. Matching physical sex characteristics to a person’s gender identity, whether through starting hormones or surgical treatment, is a key factor in protective mental health. 

Getting support through BetterHelp

If you’re interested in seeking therapy but are unable to find an informed, empathetic provider near you or face financial barriers to care, you might consider online therapy. With an online therapy platform like BetterHelp or TeenCounseling for those aged 13–19, you can meet with tens of thousands of licensed mental health professionals virtually.

You can request a therapist who suits your particular needs before the matching process begins, which may be helpful for those who would prefer to speak with a queer therapist and/or a therapist of color. 

Once matched, you can connect with your therapist via phone, video call, and/or in-app messaging from the comfort of home—all for an affordable price.

Research suggests that there’s “no difference in effectiveness” between online and in-person therapy, so either can be effective for those seeking treatment of a variety of mental health conditions, or support for other mental health concerns.