Jamie’s experience is typical of the stressors gender minorities experience that have an impact on their mental health. Despite supportive parents and accommodation from his school, Jamie experienced bullying, a sense of noninclusiveness among his peers, and limited acceptance of his gender identity. Much of the anxiety he experienced coalesced around his use of the gender-based facilities that corresponded to his gender identity.
Transgender individuals experience markedly higher rates of depression and suicidal ideation than the general population. The gender minority stress model posits that transgender individuals experience four distinct external stress types: victimization, rejection, discrimination, and identity nonaffirmation (1). A growing literature describes the internalization of these stressors and the resulting psychiatric pathology, including anxiety, depression, and suicidality (2–4). In the case of Jamie, his experiences of victimization, rejection, and identity nonaffirmation in the school setting likely played an important role in the development of his internalized transphobia (i.e., his feeling that his maleness was fraudulent) as well as his psychiatric symptoms.
Of these external stress types, identity nonaffirmation has become a major focus of national conversation in the United States in the context of the debate regarding gender-based bathroom laws. Recent surveys of transgender individuals have highlighted the potential role of identity affirmation in mitigating psychiatric morbidity. The TransYouth Project found that transgender children who were allowed to socially transition to their identified gender and were supported in their identity exhibited typical rates of depression and self-worth and only minimally elevated levels of anxiety compared with national averages (2, 4). More specifically germane to the gender-based bathroom debate, the National Transgender Discrimination Survey found that transgender adults who had been denied access to gender-appropriate bathrooms while in college had higher lifetime rates of suicide attempts (5). Although far from conclusive, these findings suggest that bathroom access that affirms an individual’s gender identity can be seen as a form of secondary prevention of mood and anxiety disorders for transgender young people. While it is true that victimization, rejection, and discrimination continue despite laws supporting bathroom choice for transgender individuals, there is some evidence to suggest that the mere presence of such laws can have mitigating effects. Data from the Youth Risk Behavior Surveillance System showed a decrease in suicide attempts by adolescents in states that adopted same-sex marriage policies. This association was most pronounced among gay, lesbian, and bisexual students (6). These findings extend the debate on gender-based bathroom laws beyond the civil rights realm and into the realm of psychopathology risk reduction, and they offer the mental health field a basis for a cogent argument for advocacy for these rights.
References
1.
Testa RJ, Habarth J, Peta J, et al: Development of the Gender Minority Stress and Resilience measure. Psychol Sex Orientat Gend Divers 2015; 2:65–77
Durwood L, McLaughlin KA, Olson KR: Mental health and self-worth in socially transitioned transgender youth. J Am Acad Child Adolesc Psychiatry 2017; 56:116–123.e2
Raifman J, Moscoe E, Austin SB, et al: Difference-in-differences analysis of the association between state same-sex marriage policies and adolescent suicide attempts. JAMA Pediatr 2017; 171:350–356
The authors report no financial relationships with commercial interests.
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