Sexuality and gender are social constructs, which may differ depending on the norms of society (Reis & Carothers, 2014). In a heterocentric society, certain attributes are reserved to describe either male or female individuals, with characteristics such as aggressive and strong being relegated to males and women being considered as more caring and emotional (Reis & Carothers, 2014). However, not all individuals fit neatly within the categories dictated by society and the challenges of individuals who are treated as “outliers” of society’s norm can be overwhelming, leading to emotional and physical distress, bullying, and social inequalities that have the ability to impact every aspect of one’s life.
Sexuality and gender can be broken down into a variety of categories, including gender identity, gender expression, biological sex and sexual orientation (Westbrook & Schilt, 2014). Research suggests that an individual’s sex is actually made up of nine factors, but it is best defined as “the outside physical or perceived surface identity of a person” (Marino, 2013). Gender identity refers to how an individual personally identifies themselves; this could include male, female, agender, bigender, gender fluid and gender queer (www.glaad.org/transgender/allies). Gender expression pertains to the external expression of gender or how someone chooses to present and be perceived in society (Westbrook & Schilt, 2014), thus is his or her “core identity or true sense of self” (Marino, 2013). Biological sex is generally broken down into three components: genitalia, chromosomes and hormones. Sexual orientation is considered to define which sex or gender you are attracted to sexually and romantically, including terms such as pansexual, heterosexual, homosexual, homoflexible, heteroflexible, asexual and bisexual (www.glaad.org/transgender/trans101).
Transgender is an umbrella term that encompasses any variety of people who don’t identify with the gender assigned to them at birth (Bradford, Reisner, Honnold, & Xavier, 2013). Transgender individuals can also vary in their gender identities (genderqueer, bigender, gender-fluid), and in their gender expression (masculine, feminine, or neither) (Singh, 2012). Therefore, the entire gender spectrum can be considered transgender; however, transgender individuals are not necessarily transsexuals. Transsexual people also don’t identify as the gender identity assigned to them at birth, however, they go on to pursue hormone replacement therapy and/or sexual reassignment surgery. This becomes very complex as individuals who pursue only hormonal changes may identify as either transgender or transsexual, depending on their own perceptions, potential stigma or discrimination, and social support. In contrast, a person who identifies as the gender assigned to them at birth is called a cisgender individual.
Mental Health Challenges
The visibility of transgender individuals in society has increased exponentially over the last ten years. We can look and see shows like “Glee” and “Orange is the New Black” and see a rise in awareness of transgender populations. However, such awareness does not always translate into acceptance within society. When it comes to the amount of research that is focused on the LGBT population, less than one percent addresses LGBT health concerns (Coulter, Kenst, Bowen, & Scout, 2014). Based on the limited amount of data available, compared to cisgender individuals, transgender individuals face rates of suicide, homelessness, anxiety and depression that are arguably of epidemic proportions. The rate of suicide attempts in the United States is 4.6 percent for the national average. The transgender population percentage of suicide attempts nationally includes 46 percent of transgender men and 42 percent of transgender women in the United States (Haas, Rodgers, & Herman, 2014).
Challenges within the realm of mental health appear to be more prevalent within the transgender community when compared to cisgender individuals. Anxiety rates for transgender populations range from 26 percent to 38 percent (Hepp, Kraemer, Schnyder, Miller & Delsignore, 2005; Mustanski, Garofalo, & Emerson, 2010), which is nearly 10 percent higher than the anxiety rate reported for the United States population (Budge, Adelson, & Howard, 2013). Likewise the rates of depression for transgender populations are reported to be higher than that of the general population, which range from 48 percent to 62 percent, which is nearly four times the rate present in the United States population (Budge, Adelson, & Howard, 2013). There appears to be a gender difference between the transgender community regarding the incidence of both anxiety and depression, with more depressive symptoms been reported by transgender women, and more anxiety symptoms reported by transgender men (Budge, Adelson, & Howard, 2013). Research suggests that the difference in psychological distress and experience of anxiety and depression among transgender women and men may be explained biologically, specifically due to the hormonal differences. According to Bockting, Miner, Romine, Hamilton, and Coleman (2013), transgender women may have a more difficult time passing (as the opposite gender) due to the difference between masculinizing and feminizing hormones used during transition. It is suggested that the easier ability to pass combined with the acceptance of nontraditional gender roles helps to explain why the rates of depression are higher among female transgender individuals compared to their male counterparts (Bockting, Miner, Romine, Hamilton, & Coleman, 2013).
Living and working in a heterosexist environment as a transgender individual can increase the stigma associated with being different from society’s terms. A feeling of isolation from social supports can lead to a greater incidence of psychological distress, which, according to research, has been linked to the higher rate of suicide within the LGBT community (Kelleher, 2009). Originally the increase in suicidal ideation was believed to be associated with the LGBT identity, but recent research has revealed that the higher rates of depression, anxiety, and suicide are instead attributed to the negative social conditions and unfair treatment individuals find themselves living with as a result of their LGBT identity (Kelleher, 2009). Research into the higher levels of psychological distress that is witnessed within the transgender community has sparked much interest in studying how the impact of the stigma held by both the individual and society contributes to the greater rates of psychological and emotional challenges faced within the community.
One theory that has been shown to be beneficial when trying to understand the occurrence of psychological distress within the LGBT community is the Minority Stress Model, which suggests that the distress is caused by a variety of factors (stigma, prejudice, and discrimination) which combined, create not just psychological distress, but act as psychosocial stressors (Kelleher, 2009). Minority stress, in particular related to sexual minorities such as the transgender community, is thought to be due to a complex mix of variables that are related directly to the sexual minority status, which include concealment, confusion, rejection (both real and anticipated), victimization, discrimination, and internalized stigmatization (Edwards & Sylaska, 2013). As these variables suggest, the source of the distress is not relegated to the external environment, as research into minority stress proposes that,
“Minority stress processes can be both external-consisting of actual experiences of rejection and discrimination (enacted stigma)-and as a product of these, internal, such as perceived rejection and expectations of being stereotyped or discriminated against (felt stigma) and hiding minority status and identity for fear of harm (concealment)” (Bockting, Miner, Romine, Hamilton, & Coleman, 2013, p. 943).
In order to lessen the experience of psychological distress, some within the transgender community have taken a dangerous course of action, namely self-performed surgeries and hormone replacement using either nonmedical sources or non-prescribed hormones in order to make their outward appearance to align with their internal gender identity. While relatively uncommon, a recent study consisting of 433 Canadians in the transgender community, five reported (one percent) having either performed or attempted self-surgery (Rotondi et al., 2013). The removal of one’s breasts or testes can be dangerous in a medical environment, and even more so when attempted in a non-surgical environment. However, the desire to align the outside with the inside proves to be too much of a lure to prevent the practice from happening. Another factor that appears to be driving the dangerous practice of using non-prescribed hormones and self-performed surgery is the access to sex-reassignment services. While certain procedures are covered by health insurance plans (vaginoplasty, mastectomy, phalloplasty, etc.), the approval process to obtain such services is often long, with many hurdles for an individual to jump through to make one’s external match one’s internal gender identity (Rotondi et al., 2013).
Another source of psychological distress can be attributed to high rates of violence that is experienced by members of the transgender community. It is estimated that 60 percent of transgender individuals have been victims of physical violence, with 46 percent experiencing sexual assault (Testa et al., 2012). Research into physical violence reveals that transgender individuals are more likely to experience physical violence by complete strangers at a rate of nearly twice that of acquaintances while sexual assaults were more likely to be carried out by an acquaintance (Testa et al., 2012). However, due to historical underreporting, the incidents are likely to be higher than what has been reported, as only 10 percent of attacks are ever reported to authorities (Testa et al., 2012). By not pursuing legal recourse, victims of assault are more prone to self-medicate with alcohol and illicit substance use, and attempt suicide more often than the cisgender population (Testa et al., 2012).
Social Inequality Challenges
While depression, anxiety, homelessness, and other social inequalities may be overwhelming each on their own, research has revealed that members of the transgender community are also at an increased risk of being victims of violence and abuse at the hand of either their partner or strangers. The ostracization from social supports may help to explain the positive relationship that exists between mental health issues such as depression, and abuse that occurs due to the transgender status (Budge, Adelson, & Howard, 2013). Just as the Minority Stress Model helped to explain a link between discrimination and psychological distress, it too can help to understand the impact social inequalities have on members of the transgender community.
Discrimination within the workplace is prohibited in the United States by the Equal Employment Opportunity Commission. However, the protection does not necessarily apply to members of the transgender community and there is little recourse that can be taken when injustices occur, which are based on sex-normative stereotypes (Marino, 2013). Restroom use and workplace attire pose challenges in the workplace for members of the transgender community since the outward appearance presented does not match the internal gender identity. Workplace discrimination does not just affect the employment status of an individual, but research indicates that such an inequality is associated with a decreased job satisfaction, increased psychological distress (specifically depressive and anxiety symptoms), and a variety of health-related issues (Brewster, Velez, DeBlaere, & Moradi, 2011). When transgender individuals who have been victims of workplace discrimination attempt to bring charges against their employers for wrongful termination, the legal system has not shown to be sympathetic nor attentive to the needs of the wronged. If charges are filed against the employer, often the transgender individual is subject to personal questions regarding his or her gender and sexual identity, delivering judgments that are based on outdated social and cultural normative standards and stereotypes regarding the roles males and females should fill (Marino, 2013). Thus “gender discrimination” does not provide ample coverage for everyone who can fall victim to the practices. Part of the reason members of the LGBT community are not provided sufficient coverage from workplace discrimination may stem from the legal system’s continued fear of showing support for conduct that falls outside of social norms, which could be viewed as “an endorsement of homosexual conduct” (Marino, 2013).
Although the legal system should, in theory, be in place to protect all individuals, regardless of gender identity, such is not the case. The inequality in protection can be seen in the recourse available and pursued when a transgender individual is the victim of bullying or violence. Transgender individuals and others within the LGBT community are, due to their minority status within society, are subject to hate crimes, which can result in psychological distress for both the victim and their families. Hate crimes consist of crimes that are “motivated by biases based on race, religion, sexual orientation, ethnicity/national origin, and disability” (Pennington, Wechsler, Clark, & Nagle, 2013). One event within the LGBT community that sparked the need for increased legal protection was the murder of Matthew Shepard in 1998. However, despite the outpour of support in providing coverage for the LGBT community from hate crimes, the advancement in any proposed legislation to bring about such change has been stymied, in part, by political consciousness (Cramer et al., 2013).
Adults are not the only ones who experience discrimination, as transgender youths are victims of severe bullying at school, where the environment is often hostile towards gender minority students. A recent study revealed that over half (62 percent) of LGBT students aged 13 to 18 were the recipients of negative remarks based on his or her gender expression (Goldblum et al., 2012). In an environment that is monitored by adults who are often thought of as role models, when LGBT students were victimized in the presence of a teacher, the behavior was stopped 12 percent of the time, with transgender students reporting feeling more unsafe at school (76.3 percent) when compared to their lesbian, gay, and bisexual counterparts (52.9 percent) (Goldblum et al., 2012). With such an increased level of psychological distress at school, transgender students are at a high risk of developing depression, anxiety, and low self-esteem, as well as suicide attempts (Goldblum et al., 2012). The hostile environment also contributes to students leaving school, with an estimated 15 percent citing severe harassment as the reason for leaving (Tebbe & Moradi, 2012). In a study consisting of 290 transgender students, over a quarter (28.5 percent) reported a history of suicide attempts, with over one third (39.0 percent) reporting three or more suicide attempts. Research suggests that transgender students of color may experience greater discrimination and prejudice when compared to their Caucasian transgender counterparts (Singh, 2013), which may be an indication of society’s inability to accept both color and transgender.
If the suicide attempts are not successful and the LGBT students are able to progress into adulthood, they can expect to experience some sort of intimate partner abuse. Some studies suggest that “significant numbers of transgender people are subjected to intimate partner abuse,” with some estimates indicating that close to 60 percent of transgender individuals will experience intimate partner abuse at some point during the course of their lifetime (Goodmark, 2012). Research suggests that intimate partner abuse within the transgender community may be caused by the same factors in cisgender relationships: controlling and enforcing gender norms; however, the incidence may be higher due to the fact that transgender individuals do not conform to society’s version of gender norms (Goodmark, 2012). Similar to the treatment transgender individuals receive when reporting incidents of workplace discrimination, victims of intimate partner violence also receive unfair treatment, with nearly one third reporting being disrespected or harassed by the police department (Tebbe & Moradi, 2012). While law enforcement is, in theory, supposed to protect and serve, it appears that the men and women who comprise the legal system (including the police officers, judges, juries, etc.) mirror the attitudes held by the national population towards members of the transgender population. Research into the attitudes held by Americans in regards to transgender individuals reveals that heterosexual men are more likely to view transgender people more negatively when compared to heterosexual females, but it appears that both genders of the cisgender population view transgender individuals in a negative light (Norton & Herek, 2013). As the level of psychological authoritarianism, political conservatism, and religiosity increased, so does the level of prejudice towards transgender individuals (Norton & Herek, 2013).
While the amount of discrimination, social inequalities, and mental health challenges faced by members of the transgender population appear to be overwhelming, there are methods that have shown to be effective in combating the negative messages members of the LGBT community receive. The dissolution of social support that occurs when a transgender individual “comes out” as transgender, a feeling of rejection is often experienced by the individual by their family, friends, and even significant others. Although research has suggested that the majority of the cisgender population within the United States hold a negative view when it comes to the transgender population (Norton & Herek, 2013), there are others that work to provide a safe environment for the members of the community.
An empathetic therapist who is aware of the shame many transgender individuals feel can help to build a therapeutic alliance and help his or her client to learn effective coping skills that can help to provide protection from the hurtful and discriminating environment transgender individuals find themselves experiencing. Research has shown that shame is one of the more common emotions felt by members within the LGBT community, which some believe occurs along a continuum, ranging from mild embarrassment, to mortification (Longhofer, 2013). Learning how to overcome the shame that is placed on transgender individuals by society can help to alleviate some of the other negative feelings and emotions, thus lessening the level of psychological distress experienced (Budge, Adelson, & Howard, 2013).
Social support has also shown to be a good insulator against the negative aspects that are associated with discrimination and ostracization from society. Research suggests that there are two different types of social support: general and sexuality-specific, with each contributing different beneficial support to transgender individuals (Sheets & Mohr, 2009). General social support has been linked to greater self-esteem, a decrease in loneliness and depression, and an overall better psychosocial adjustment (Sheets & Mohr, 2009). Support from parents and other family members is also helpful, as research suggests that support from such individuals leads to a higher quality of life and lower levels of depression experienced by a transgender youth (Simons, Schrager, Clark, Belzer, & Olson, 2013). Sexuality-specific social support can also help to foster self-esteem, but since it is geared more towards the acceptance of being a transgender individual, the sexuality-specific social support can help to facilitate social integration (Sheets & Mohr, 2009).
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