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Anxiety and Depression in Transgender Individuals: The Roles of
Transition Status, Loss, Social Support, and Coping
Stephanie L. Budge and Jill L. Adelson
University of Louisville
Kimberly A. S. Howard
Boston University
Objective: The purpose of the current study was to examine facilitative and avoidant coping as mediators
between distress and transition status, social support, and loss. Method: A total of 351 transgender
individuals (n⫽226 transgender women and n⫽125 transgender men) participated in this study.
Participants completed measures on transgender identity, family history of mental health concerns,
perceptions of loss, coping, depression, and anxiety. Results: The rates of depressive symptoms (51.4%
for transgender women; 48.3% for transgender men) and anxiety (40.4% for transgender women; 47.5%
for transgender men) within the current study far surpass the rates of those for the general population.
Structural equation modeling (SEM) was used to analyze the data—2 separate models were hypothesized,
based on reports of anxiety or depression. The SEM results suggest that the processes for transgender
women and transgender men are primarily similar for depression and anxiety; avoidant coping served as
a mediator between transition status and both distress variables. Social support was directly related to
distress variables, as well as indirectly related through avoidant coping. Conclusion: Results suggest the
need for practitioners to focus on interventions that reduce avoidant coping strategies, while simultane-
ously increasing social support, in order to improve mental health for transgender individuals. Individuals
who are in the beginning stages of their transition will use different coping strategies than those who are
in later stages; interventions should be adjusted on the basis of the transition status of transgender clients.
Keywords: transgender, anxiety, depression, coping, social support
Transgender individuals are particularly vulnerable to mental
health concerns and psychological distress (Nuttbrock, Rosen-
blum, & Blumenstein, 2002). Regarding specific psychological
distress, research has shown that transgender individuals report
higher levels of both anxiety and depression than the population as
a whole. Depression has been reported to affect 16.6% of the total
population, and combined anxiety disorders affect 28.8% of the
United States population (Kessler, Berglund, Demler, Jin, & Wal-
ters, 2005). Within the literature, rates of depression for transgen-
der individuals range from 48% to 62% (Clements-Nolle, Marx,
Guzman, & Katz, 2001;Nemoto, Bodeker, & Iwamoto, 2011;
Nuttbrock et al., 2010). Anxiety and overall distress rates for
transgender individuals range from 26% to 38% (Hepp, Kraemer,
Schnyder, Miller, & Delsignore, 2005;Mustanski, Garofalo, &
Emerson, 2010).
Although the rates of depression, anxiety, and overall distress
indicate above-average rates for the transgender population, there
are only several studies that examine potential explanations for
these findings. Nuttbrock et al. (2010) report that there is a sig-
nificant positive relationship between gender-related abuse and
depression in transgender women. The authors note that social
stressors and/or ostracism from peers can explain a large amount
of the depression that is reported by the individuals in their study.
Budge et al.’s (2012) qualitative study indicates that distress varies
on the basis of several factors, including the individual’s transition
process, coping mechanisms used, and level of social support.
Although both of these studies provide insight into possible ex-
planations for contributing factors to transgender individuals’ dis-
tress, there continues to be a lack of generalizable information
regarding the actual process through which individuals cope with
and experience depression and anxiety.
Coping mechanisms have been theorized to buffer the effects of
psychological distress due to stigma, internalized homo(or trans)pho-
bia, and experiences of discrimination and violence (Meyer, 2003).
Internalized transphobia is a result of internalizing negative mes-
sages based on societal expectations of what is considered to be
“normal” (i.e., not deviating from gender norms) (Bockting &
Coleman, 2007). As transgender individuals negotiate in a world
that is rarely accepting of them, it is critical that the types of coping
mechanisms (both adaptive and maladaptive) are better under-
stood. It has been theorized that there are two general categories of
This article was published Online First February 11, 2013.
Stephanie L. Budge and Jill L. Adelson, Department of Educational and
Counseling Psychology, Counseling, and College Student Personnel, Uni-
versity of Louisville; Kimberly A. S. Howard, School of Education, Boston
University.
We thank Bruce Wampold, (Department of Counseling Psychology,
University of Wisconsin—Madison), David Kaplan (Department of Edu-
cational Psychology, University of Wisconsin—Madison), Lee Nelson
(Department of Counseling and Family Therapy, University of Missouri—
St. Louis), and Teresa Bear (Department of Psychology, Alverno College)
for their statistical assistance and helpful comments on a draft of this
article.
Correspondence concerning this article should be addressed to Stephanie
L. Budge, Department of Educational and Counseling Psychology, Coun-
seling, and College Student Personnel, University of Louisville, Louisville,
KY 40292. E-mail: stephanie.budge@louisville.edu
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Journal of Consulting and Clinical Psychology © 2013 American Psychological Association
2013, Vol. 81, No. 3, 545–557 0022-006X/13/$12.00 DOI: 10.1037/a0031774
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