To what extent does lack of support influence the development of depressive symptoms in transgender people among other sociocultural factors?

Transgenderism, according to the American Psychological Association, can be defined as a broad umbrella term referring to individuals who continuously identify with a gender that differs from the one assigned to them at birth. A person who identifies with the sex they were assigned at birth would be described as ‘cisgender’. In other words, a person may identify as transgender when the sex they were assigned at birth through the visual inspection of their genitals is not congruent with their gender identity - one’s sense of oneself as male, female, or else (American Psychological Association, 2015). The term ‘transgender’ includes both binary gender identities, such as trans men and trans women and non-binary trans identities, such as genderqueer, agender, genderfluid, or else (Richards et al., 2016).

 

Identifying as transgender does not constitute a mental disorder (American Psychological Association, 2011). Trans people can be given the diagnosis of gender dysphoria (F64.1), which is described by the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a clear incongruence between one’s self-perceived/identified/expressed gender and the one assigned at birth. However, transgender individuals encounter obstacles that may lead to psychological distress. There is a social stigma attached to the gender expression of transgender people, which results in them experiencing discrimination, victimization, and harassment. Social stigma is defined by the APA dictionary of psychology as ‘the negative social attitude attached to a characteristic of an individual that may be regarded as a mental, physical, or social deficiency.’ These experiences may lead to the development of depressive symptoms which occur at higher rates in transgender people (Borgogna, McDermott, Aita and Kridel, 2018). Depression has been reported in 16.6% of the general population (Kessler net al., 2005), while records of depression in trans people have been as high as 54.7% (Nuttbrock et al., 2010).

 

Major depressive disorder, commonly known as depression, is a serious mental illness that affects negatively how a person feels, thinks, and acts (American Psychiatric Association, 2013). Some of the most common depressive symptoms can include: feeling sad, trouble sleeping, losing interest in things once enjoyed, loss of energy, feeling worthless, difficulty in concentration, thoughts of suicide. Depressive symptoms can cause a wide range of emotional issues and hinder one’s ability to function properly.

 

The higher rate of depressive symptoms in transgender persons can be explained by the minority stress model. The minority stress model (Meyer, 2003) may be used as an explanation for the excessive stress experienced by minority communities with comparison to dominant groups, which are distinguished by the level of the social stigma that they experience. Societal situations in which dominant communities are normative may activate the minority stress model. Social norms oftentimes do not reflect upon minority cultures. An example of a social structure conflict is the lack of non-heteronormative, transgender representation in the media. As the minority stress model derives from numerous different psychological and sociological theories, there is a varied spectrum of understanding the theory. Furthermore, researchers find it plausible that the unique kind of stress that minorities experience contributes to the further development of mental and physical disorders (Dentato, 2012). The theories that conclude the higher possibility of contracting HIV in males who have sexual intercourse with other males often believe that minority stress may be an indirect cause for sexually transmitted infections. For instance, minority stress may cause reckless behaviors such as sexual promiscuity or omitting the usage of condoms, which then can lead to transmitting STDs. Concerning the transgender population, minority stress factors can be expressed both externally and internally. These processes would include a real-life example of discrimination along with internalized transphobia. Support of peers and family, community belongingness, and self-acceptance allow for a decrease in the occurrence of minority stress, which consecutively results in the decrease in the rate of psychological distress. The minority stress model (Meyer, 2003; Meyer, 2015) distinguishes various factors as minority stressors and minority stress processes that can both positively and negatively influence mental health outcomes in minority groups. These, of course, include coping and social support (community and individual) among prejudice events (discrimination, violence), expectations of rejection, concealment, and internalized homophobia/transphobia (Meyer, 2003).

 

The research question weighs significance in the face of current world events - To what extent does lack of support influence the development of depressive symptoms in transgender people among other sociocultural factors? Over the years, studies have examined the effect of sociocultural factors on the development of depressive disorders in minority groups incl. transgender individuals. Hence, it can be hypothesized that lack of support influences the development of depressive symptoms in transgender people to a notable extent (as supported by research). Nemoto et al. (2011), Simons et al. (2013) and Boza & Perry (2014) are used to discuss the influence of social support and compare it with other factors proposed by Meyer in 2003. Nuttbrock et al. (2015), Barr, Budge, and Adelson (2016) and Testa et al. (2014) consider the significance of community involvement. Nuttbrock et al. (2010), Grossman et al. (2007) and Bazargan & Galvan (2012) investigate the influence of gender-related abuse on the development of depressive symptoms in transgender people.

Above - average rates of depressive symptoms are characteristic of the transgender community and numerous studies have been conducted to investigate the reasoning behind their mental health trajectory. Nemoto et al. (2011) investigated the correlation of transphobia, violence, and social support with depression in transgender women with a history of sex work. A total of 537 trans women were recruited to participate in an individual interview and fill out a structured questionnaire. Depressive symptoms were measured using the Depression Scale [CES-D], which is a widely used resource for recording depressive symptoms. A modified version of the Social Support Scale was used to measure the frequency of receiving social support from family, transgender friends, and cisgender friends over the course of the last 30 days. Background demographic information was collected. Participants of the study who reported less frequent receipt of social support were more likely to experience depressive symptoms (as measured by the CES-D) than other participants. The correlation between received social support and depression in participants was estimated to - 0.08. According to the study, depressive symptoms were directly and significantly (P<.06) correlated to lower levels of receiving social support. The results of the study cannot be named applicable to the general population of transgender people, as the study was targeted at transgender women with a history of sex work (purposive sampling). Response bias has to be considered in regard to social desirability (since the method of individual interviews was implemented), human error of retrospective memory, and demographic disproportions (two-thirds of the participants were 30 years of age and up, 41% were African American, nearly 60% of them earned less than 1000 dollars a month). The results of study definitely support the hypothesis that social support is negatively correlated with depressive symptoms in trans people. However, the study mostly confirms the correlation in women of color, where racism and colorism could also be considered as factors influencing social support. Parental support is one of the vital protective factors over depressive symptoms and suicidality among sexual minorities (Eisenberg & Resnick, 2006). However, most studies focus on the LGBTQ+ community as a whole, with few of them investigating the problem of family support toward transgender individuals. Simons et al. (2013) looked into the relationship between parental support and depression in transgender adolescents. 66 transgender (specifically gender nonconforming) young adults completed a computer- assisted survey recording, among others, demographics, parental support, and symptoms of depression. The Multidimensional Scale of Social Support was utilized to assess the level of parental support, whereas the Beck Depression Inventory II assessed the existence and severity of depressive symptoms. Higher parental support appeared to be significantly (P=.05) associated with fewer depressive symptoms. The results suggest that parental support is crucial in the prevention of the development of depressive symptoms in transgender youth. The examined group was demographically diverse, with 48.5% of the participants being assigned male at birth (AMAB) and 51.5% of them being assigned female at birth (AFAB); 51.5% of them being Caucasian and 48.5% being people of color. The results may have been altered by self-reporting bias. The sample is not representative of all transgender youth, as it consisted purely of adolescents presenting for hormone therapy at a medical center in Los Angeles. The parental support measure did not distinguish between one or more parents and did not specify support regarding the subject’s gender identity. Even though the study lacks in method diversity and distinction, it is significant regarding transgender adolescents. It explains that family support has a protective role in the life of trans people and a positive influence on their mental state.

 

An Australian survey (Tranznation) reported 36% of participants experiencing depressive symptoms (Couch et al., 2007). Boza & Perry (2014) conducted a survey among 255 transgender Australians investigating the predictors of their mental health outcomes. The aim of the study was to establish the predictive value of how perceived social support has an influence of the development of depressive symptoms. Purposive sampling was utilized through email advertising to recruit transgender participants over the age of 18 residing in Australia. The participants answered sociodemographic questions, their depressive symptoms were measured by the CES-D and the perceived social support was recorded using the Multidimensional Scale of Perceived Social Support (MSPSS). The results presented a small, but significant (P<.05) correlation between lack of support and depressive symptoms. Among other predictors, social support emerged as the most significant factor contributing to the mental health trajectory of transgender people. As the sample was recruited through advertising among transgender community groups, the sample may have not included inactive members of the transgender community. The study may have been ethnically biased toward those of European descent (94.2%) and AMAB individuals (66%). The researchers did not take into consideration confounding variables such as drug use, sexual risk behaviors or HIV-positive status which can have a negative impact on mental health. The findings represent a major mental health concern for trans people. Overall, the results suggest that depression symptoms are widespread among transgender people and lack of social support is one of the most determining factors.

 

In every examined study, social support seems to have a significant impact on the mental trajectory of trans people. It falls into the category of individual support as a minority stressor. Lack of social support is definitely correlated with depressive symptoms. Even though the results of the studies are limited in generalization, they provide insight into the discussed problem. Despite of the confounding variables and biases in the research, social support stands out as a determining factor in the development of depressive symptoms in trans people.

Surprisingly, studies have also suggested that community involvement within people with a shared stigma may be associated with the mental state of transgender people. Nuttbrock et al. (2015) extended the line of prior research on this topic with the first longitudinal study. Basing on different, small-scale studies (e.g. Sanchez & Viliain, 2009 or Singh, Hays & Watson, 2011) Nuttbrock hypothesized that psychological distress in trans people, demonstrating itself as depressive symptoms may be moderated by the level of involvement with the transgender community. 571 transgender women were recruited to participate in the study. The participants’ involvement in the transgender community was examined with a series questionnaires of with reference to the prior six months. The questions asked about any social events, websites, or meetings taken up by the participant within their community. Then the results were added on a scale of 0 through 5. Major depression symptoms were assessed using the Mini International Neuropsychiatric Interview (M.I.N.I). Assessing the course of the prior six months, major depression was coded positive if diagnostic symptoms were recorded. Transgender community involvement proved to be associated with major depression symptoms. Among those with the lowest community involvement, the probability of being depressed was recorded at 31.6% prevalence (contrary to the highest community involvement - 7.7%). The longitudinal research model was definitely a strength of the study, along with the diagnostic major depression follow-ups. The fact that the participants were not randomly selected and were not diverse over geographical locations could be considered as a limitation. None of the participants have tested HIV-positive, which is a recurring factor in other transgender- based studies. The mechanisms of community involvement could also be better specified across the assessments carried out. The results are, however, critically important. They suggest that by uniting and grouping, trans women may counteract the negative mental challenges coming their way. Barr, Budge, and Adelson (2016) conducted a study examining transgender community belongingness and its relation to psychological well-being in 571 trans men, trans women, and non-binary individuals. The participants were recruited through United States - based LGBTQ+ organizations, offices, colleges, groups, and centers, and social media networks. The survey was open for six weeks to all transgender people over the age of 18. The Lesbian Community Belongingness Scale was adapted for the needs of the study to assess the transgender community belongingness over a 5 -point Likert scale. The participants reacted to 10 statements describing a sense of transgender belongingness. Psychological well-being was assessed using Ryff’s (1995) 18 - item Scale of Psychological Well- Being (SPWB). The scale allowed for a record of depressive symptoms such as no sense of purpose in life, lack of self-acceptance, or low self-esteem. As hypothesized, the estimated results indicated a positive relationship of moderate size between transgender community belongingness and psychological well-being (β=0.249, p<.001). Even though the study examined a wider range of transgender identities, a nuanced investigation of particular identities was not possible. It was also mostly racially unified as 80% of the participants indicated their race to be non-Hispanic white. Furthermore, the study cannot make claims about the causality of variables as it is correlational in nature. In summary, it can be concluded that high levels of transgender community belongingness predict high levels of psychological well-being. Transgender community belongingness appears to be a vital indicator of transgender people’s mental well - being.

 

Another example of research examining how the connection to transgender communities may be mentally protective is Testa et al. (2014). This study aimed to investigate how trans individuals’ risk of various depressive symptoms is related to their connection with other trans people. The researchers analyzed an anonymous survey The Lives of Transgender People (Beemyn & Rankin, 2011) which provided all information about transgender experiences needed to prove or disprove their hypothesis. A total of 3087 people answered questions regarding their demographics and mental state in relation to their transgender identity and encounters with other trans people. The results showed that trans participants who had been in any relations with other transgender people, both prior and subsequent to their coming out, were less likely (by 8 to 17% in every condition) to experience fearfulness, suicidal ideation, and psychological discomfort, which are depressive symptoms. There are several limitations to this study. The results are based on retrospective self-report data that cannot establish a sense of causality between the variables. The participants were mostly white and belonged to the young demographic. The generalization of the sample is unclear. The findings indicate that having awareness of trans people decreases fearfulness, suicidality, and mental discomfort. For both AMAB and AFAB participants, the results suggest that experiences, either prior or subsequent to the coming out, with other trans people are significant for high psychological well - being.

 

Although the constructs between transgender people remain mostly unexamined, research has acknowledged the importance of community belongingness. Community involvement can be defined as community support in terms of the minority stress model (Meyer, 2003). The predictive abilities of research may be limited due to the small-scale examination and restricted resources. However, in the above-mentioned studies sense of belongingness has proven to be associated with a decrease in depressive symptoms.

Transgender people are oftentimes victims of interpersonal abuse because of their gender identity or presentation. Experiencing such abuse may have a negative psychiatric impact. Nuttbrock et al. (2010) aimed to investigate the effect of psychological and physical abuse on major depression in transgender individuals. 571 male-to-female (MTF) participants of various ages, backgrounds, and sexual orientations were interviewed face- to-face according to the Life Review of Transgender Experiences. It is a protocol designed specifically for MTF trans individuals assessing their social, behavioral, economic, and psychiatric experiences. Major depression symptoms were assessed by the M.I.N.I. scale and the participants were asked about the experience and frequency of gender abuse throughout different life stages. The hypothetical effects of gender-based violence on suicidal activity are generally supported in all four life-stage changes, with some exceptions. In comparison to the most commonly reported effects of abuse on clinical depression in the early life stages, substantial effects of abuse on suicidal behavior have been observed over the course of life, especially among older respondents. The use of retrospective self-reported data can be deemed as a limitation of the study, along with the New York-based, Hispanic domination of participants. By looking across different stages of life, the effect of gender-related abuse can be best understood and demonstrated. Even though direct casualty cannot be established, it is strongly suggested by the effects of gender abuse across adolescence. The findings of this research fit into the previously discussed literature.

 

As already mentioned, life-threatening behavior such as attempted suicide, self- injury, or taking drugs can be considered a depressive symptom. Grossman et al. (2007) investigated the influence of (parental) physical and verbal abuse on the development of life-threatening behavior in transgender youth. 55 MTF and FTM participants aged 15 - 21 participated in a questionnaire and a structured interview. They were asked about any life- threatening actions and their frequency (Likert scale). The investigated behaviors were specifically divided into suicide attempts, suicidal ideation, and drug use. The used questions were similar to those used in earlier studies examining LGBT youth. The prevalence of parental abuse was measured using the Child and Adolescent Psychological Abuse Measure (Briere & Runtz, 1990). Among adolescents who attempted suicide (N=14) a mean of 1.51 acts of abuse was recorded, whereas a mean of 0.91 abusive behaviors was recorded among non-attempters. The recorded abuse was both physical and mental. The study examined a really small (N=55) New York City-based sample, which definitely cannot be generalized and is not characteristic of all transgender youth. The study was Hispanic, college-educated, and single-parent household dominated. All of the participants had access to community-based organizations, which eradicated the lack of community involvement as a possible confounding variable. The use of convenience sampling and self-report data allows for bias. The results demonstrate that abused transgender youth is most at risk when it comes to life-threatening behaviors in comparison to other LGBT Youth (D’Augelli et al., 2005) The investigation found that those who experienced parental abuse very more likely to attempt suicide than those who did not. It can be concluded that suicide attempts and ideation among trans youth can be attributed to gender-based abuse.

 

Alongside physical and verbal violence, gender-based abuse can also demonstrate itself as sexual violence. Bazargan & Galvan (2012) aimed to investigate the relationship between sexual mistreatment and depression severity in low-income Latina MTF trans women. 220 participants were recruited through social groups, organizations, and events in the Los Angeles area. The sample was not particularly diverse but allowed for a nuanced investigation of the subjects. The participants took part in a survey and an interview. The subjects could choose their language of preference and 98% chose Spanish. Depression severity was measured using the Patient Health Questionnaire - 9 (either the Spanish or English language version). The questionnaire measured the severity of depressive symptoms as specified in DSM-IV. For convenience, the participants were grouped into ‘Low Severity’, ‘Moderate Severity’, and ‘High Severity’ categories of clinical depression. Sexual violence and mistreatment were assessed through a series of questions. About 35% of the participants were identified with moderate to severe depression. It is therefore not surprising that those who were sexually abused or mistreated by their partner reported severe depression almost twice as often as their counterparts who were not sexually abused. The three main limitations of the study include the cross-sectional nature of it, and hence the inability to establish casualty. What’s more, the non-probability sampling hindered the generalization capacity of the findings. Finally, the questions regarding sexual abuse were limited and did not give direct insight into the issue. The findings cannot be applied to the whole transgender population, but they represent repetitive patterns observed in MTF trans women. An association between sexual abuse and major depression was identified. Sexual abuse and mistreatment lead to an increase in mental health deterioration, incl. depressive symptoms.

 

The gender-related abuse seems to have an influence on the mental health trajectory of trans people. It can be classified as a prejudiced event - a minority stressor. Nevertheless, studies examining gender-related abuse on trans people are limited and oftentimes focused onto a particular group of individuals within the community. Therefore, the impact of gender-based violence cannot be as determined as social support or community involvement.

The minority stress model (Meyer, 2003) suggests that a combination of social stressors influences the mental health trajectory of minorities. Social support, either individual or community-based, is a valid indicator of the development of mental disorders. Transgender people, burdened by mentally challenging experiences on a daily basis fit into the minority stress model. The extent of the influence of social support on depressive symptoms in transgender people was under investigation. According to research, social support seems to influence the development of major depression in trans individuals to a notable extent.

 

Social support of trans people has undergone the most thorough investigation out of all the factors studied. The range of discussed studies allows for an assumption of casualty between social support and depressive symptoms. The studies of Nemoto et al. , (2011), Simons et al (2013), and Bozza & Perry (2014) complement each other’s understanding of the cause of depression in trans people. The combination of studies on trans adolescents, trans adult women, and AMAB and AFAB transgender individuals gives direct insight into all trans identities and their mental health. This gives us the right to conclude that individual social support influences the development of depressive symptoms in transgender people to a notable extent.

 

Surprisingly, community involvement proved to have an enormous influence on the development of major depression in trans people. The results of the Nemoto et al., (2011) study may even be seen as contradictory to Nuttbrock et al., (2015), Barr, Budge, and Adelson, (2016), and Testa et al. (2014). That is, the findings of the studies may suggest that community belongingness is the most determining factor in the case of major depression in trans people. The overwhelming acceptance of hypotheses may be influenced by the fact that the studies were mostly small-scale. Nevertheless, the combination of the research results point to one conclusion - community involvement is a vital factor in the development of depressive symptoms in trans people.

 

Gender-related abuse seems to be the most limited topic in the field of research on depression in trans people. The studies are very nuanced, oftentimes only focusing on adolescent or trans women (e.g., Bazargan & Galvan, 2012 examining low-income Latina MTF women). However, there are studies examining different types of abuse - psychological, verbal, physical, sexual, etc. The findings of the research are not always clear and simple to conclude from, but they indicate that abuse is a factor influencing major depression in trans people. The impact is clearly not as strong as the ones of individual and community-based social support. Nevertheless, the impact of gender-based abuse is important to note while discussing the issue of depression among trans people

 

It can be concluded that social support stands out as a determining factor in the development of depressive symptoms in trans people. Both individual and community- based social support plays an important role in the mental health trajectory of transgender individuals. The examined studies fit into the minority stress model proposed by Meyer in 2003. The characteristics of the discussed studies call for further investigation of the problem. The research only discusses the sociocultural causes, although in further investigations, it is important to consider the possible biological and cognitive influences that contribute to depression in trans people. A lot of the research is small-scale, nuanced, and not completely generalizable. Be that as it may, all discussed research points to a significant influence of social support on the development of depressive symptoms in transgender people.

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