Gender Minority Stress, Depression, and Anxiety in a Transgender High School Student
Publication: American Journal of Psychiatry
“Jamie” looks like a typical high school sophomore boy. He is clean-cut and dressed in baggy pants, a T-shirt, and a stocking cap. Jamie was born in a girl’s body. He came out to his family as transgender when he was 14 years old. Jamie’s mother was very supportive from the start. She bought Jamie a binder to reduce the appearance of his developing breasts, and took him shopping for masculine clothing. She also sought therapy for Jamie with a provider who specialized in gender identity issues and encouraged the rest of the family to attend their own therapy to help them adjust. Jamie’s father struggled a bit more with the news. He did not say anything overtly negative, but Jamie noticed that he had become more distant, no longer spending time watching hockey games together. Jamie struggled with school avoidance, as well as self-harm by cutting and burning, and he self-medicated with marijuana. He said that he was doing everything he could to numb the difficult feelings he was experiencing. He was diagnosed with major depressive disorder by his primary care physician and after a trial of fluoxetine did not help, he was switched to escitalopram.
Within weeks of coming out to his family, Jamie felt so hopeless and overwhelmed with his desire to fully transition and be accepted by his peers and family that he took an overdose of escitalopram in a suicide attempt. Soon after taking the overdose, he disclosed it to his mother, who took him to the hospital. During his admission, he learned coping skills and decided to quit his self-harm and his marijuana use. His motivation to improve was that it would allow him to start testosterone therapy for his medical transition. He was discharged after 1 week on a medication regimen of duloxetine (for depressive symptoms), propranolol (for school anxiety), and risperidone (for mood instability).
After Jamie’s hospital admission, he and his mother presented to the University of Colorado Imagine Clinic (a specialty clinic for individuals of all ages who identify as LGBT—lesbian, gay, bisexual, or transgender) for a medication evaluation for ongoing symptoms of depression and anxiety. Jamie had missed a significant number of school days even before his hospitalization, and returning to school was a major hurdle for him to overcome. When he tried to attend school, he became tachycardic and tachypneic, and he would frequently have to excuse himself to the nurse’s office or ask his mother to come get him to calm down. Jamie explained that he felt immensely uncomfortable at school. He would compare himself to his male peers and feel that he would never be able to measure up to their “maleness,” that he was a fraud, and that he did not fit in. He feared that even after he began medically transitioning, there would never be a point at which he could feel comfortable in his own body. Jamie did not wish to attend groups with transgender peers for support, as he wanted to be identified as male rather than as transgender. At intake, Jamie was diagnosed with gender dysphoria, generalized anxiety disorder, and major depressive disorder. No medication changes were made at that time, as his depression and urges to self-harm had improved and he was scheduled to start testosterone therapy in 2 months.
The school offered Jamie the flexibility to take a reduced school day and the option of retreating to the nurse’s office whenever he needed a break during the school day or if he needed to use the restroom. He was permitted to complete his physical education credits through an online course to avoid the locker room. Those measures were helpful initially, and Jamie’s depressive and anxious symptoms improved. Jamie’s family felt satisfied with the school’s support through this difficult transition. However, as Jamie began spending more time in school, he was bullied by peers. He had a physical altercation with a peer who disparaged his gender identity. Jamie and the other boy were both suspended. After his suspension, he avoided use of the restroom at school completely, and he no longer wanted to use his accommodations to go to the nurse’s office. He stated that he would make his peers feel uncomfortable or, even worse, that he would be ostracized or bullied for using either the boys’ or the girls’ restroom. Jamie’s anxiety over being ridiculed and, at times, his fear for his safety at school led to worsening school avoidance. His anxiety escalated to multiple daily episodes of hyperventilation, and he complained of constant fatigue.
Jamie’s difficulty attending classes led him to the brink of failing his courses. The school decided to transition him fully to online school for the remainder of the school year to recover the necessary credits. He continued in therapy and medication management, with the goal of supporting his transition back to school in the fall.
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
2.
Olson KR, Durwood L, DeMeules M, et al: Mental health of transgender children who are supported in their identities. Pediatrics 2016; 137:e20153223
3.
Testa RJ, Michaels MS, Bliss W, et al: Suicidal ideation in transgender people: gender minority stress and interpersonal theory factors. J Abnorm Psychol 2017; 126:125–136
4.
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
5.
Seelman KL: Transgender adults’ access to college bathrooms and housing and the relationship to suicidality. J Homosex 2016; 63:1378–1399
6.
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
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Received: 18 April 2017
Revision received: 25 May 2017
Accepted: 5 June 2017
Published online: 1 December 2017
Published in print: December 01, 2017
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The authors report no financial relationships with commercial interests.
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