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Coping with discrimination: The insidious effects of gender minority stigma on depression and anxiety in transgender individuals

Authors:
  • Genesee Valley Psychology

Abstract

Objectives: We examined types of discrimination encountered by transgender and gender diverse (TGD) individuals and the associations with symptoms of depression and anxiety, as well as the mediating and moderating effects of coping responses. Method: This online study included 695 TGD individuals ages 16 years and over (M = 25.52; standard deviation = 9.68). Results: Most participants (76.1%) reported discrimination over the past year. Greater exposure to discrimination was associated with more symptoms of depression and anxiety. These associations were mediated by coping via detachment and via internalization, although a direct effect remained. Conclusions: Many TGD people will encounter discrimination and this is associated with greater psychological distress. Engagement in the internalization of blame or detachment partially explains the association between discrimination and mental health issues. These findings elucidate possible avenues for interventions to bolster adaptive coping responses for TGD people and highlight that actions to decrease discrimination are urgently needed.
J. Clin. Psychol. 2019;119. wileyonlinelibrary.com/journal/jclp © 2019 Wiley Periodicals, Inc.
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DOI: 10.1002/jclp.22865
RESEARCH ARTICLE
Coping with discrimination: The insidious effects
of gender minority stigma on depression and
anxiety in transgender individuals
Jae A. Puckett
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Meredith R. Maroney
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Lauren P. Wadsworth
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Brian Mustanski
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Michael E. Newcomb
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1
Department of Psychology, Michigan State
University, East Lansing, Michigan
2
Department of Counseling and School
Psychology, University of Massachusetts
Boston, Boston, Massachusetts
3
Genesee Valley Psychology, Rochester,
New York
4
Department of Medical Social Sciences,
Institute for Sexual and Gender Minority
Health and Wellbeing, Northwestern
University Feinberg School of Medicine,
Chicago, Illinois
Correspondence
Jae A. Puckett, Department of Psychology,
Michigan State University, 316 Physics Rd.,
Rm 262, East Lansing, MI 48824.
Email: pucket26@msu.edu
Funding information
National Institute on Drug Abuse, Grant/
Award Number: 1F32DA038557
Abstract
Objectives: We examined types of discrimination encoun-
tered by transgender and gender diverse (TGD) individuals
and the associations with symptoms of depression and
anxiety, as well as the mediating and moderating effects of
coping responses.
Method: This online study included 695 TGD individuals
ages 16 years and over (M= 25.52; standard deviation =
9.68).
Results: Most participants (76.1%) reported discrimination
over the past year. Greater exposure to discrimination was
associated with more symptoms of depression and anxiety.
These associations were mediated by coping via detachment
and via internalization, although a direct effect remained.
Conclusions: Many TGD people will encounter discrimina-
tion and this is associated with greater psychological
distress. Engagement in the internalization of blame or
detachment partially explains the association between
discrimination and mental health issues. These findings
elucidate possible avenues for interventions to bolster
adaptive coping responses for TGD people and highlight
that actions to decrease discrimination are urgently needed.
KEYWORDS
anxiety, coping, depression, discrimination, mental health,
transgender
Transgender and gender diverse (TGD) individuals (i.e., people whose gender identity differs from that typically
associated with their sex assigned at birth) represent a broad, marginalized group. This category includes a range of
gender identities that span from transgender men and women to identities outside of binary notions of gender,
such as genderqueer. Research thus far with this community has shown that there are significant mental health
disparities that exist for TGD people (Budge, Adelson, & Howard, 2013; James et al., 2016; PerezBrumer, Day,
Russell, & Hatzenbuehler, 2017; Reisner et al., 2015) and that exposure to life stressors partially drives these
disparities (Hendricks & Testa, 2012). It is imperative that the psychological distress experienced by TGD people be
contextualized to better understand the lived experiences of this marginalized group. This will facilitate better
conceptualization of psychological distress for TGD people and the development of more effective methods of
alleviating distress. Given the implications of this line of research, we sought to examine the association between
discrimination and symptoms of depression and anxiety, as well as the mediating and moderating roles of various
coping responses.
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MINORITY STRESS EXPOSURE FOR TGD INDIVIDUALS
As a marginalized group, TGD people may experience a range of adverse life events related to bias and stigma.
These challenges have collectively been termed minority stress, which refers to the unique stressors that minority
groups experience above and beyond the general stressors that all people may encounter (Meyer, 2003). There are
many forms of minority stress experienced by TGD people, one of which is discrimination (Hendricks & Testa, 2012;
Meyer, 2003). Discrimination may occur across a range of settings, including employment, housing, public
accommodations, and other life domains (Hatchel & Marx, 2018; Herman, 2013; Hughto White, Reisner, &
Pachankis, 2015; James et al., 2016; Messman & Leslie, 2018; Nadal, Skolnik, & Wong, 2012; Rodriguez, Agardh, &
Asamoah, 2018; Shires & Jaffee, 2015). For instance, due to prejudice against TGD people, they may be fired from
their jobs for no cause, denied employment opportunities, denied access to public facilities and settings, or other
specific discriminatory acts. In addition, currently, there are no federal laws protecting TGD people against
discrimination in employment, housing, or public accommodations and statespecific discrimination laws that are
inclusive of TGD people are limited.
It has been well documented that TGD people experience notably high levels of discrimination (e.g., McCann &
Brown, 2017) and that this has significant implications for their health and wellbeing (Bockting, Miner, Winburne,
Hamilton, & Coleman, 2013; Glick, Theall, Andrinopoulos, & Kendall, 2018). In their review of quantitative studies
on discrimination and resilience, McCann and Brown (2017) found that 4070% of TGD individuals across studies
had experienced some form of discrimination. Other individual studies have found similarly high rates of
discrimination, such as 41% of TGD individuals experiencing discrimination in any area of life (Bradford, Reisner,
Honnold, & Xavier, 2013). Furthermore, these experiences of discrimination are not only pervasive, they are also
chronic and occur with striking frequency. Bazargan and Galvan (2012) found that 25% of the Latina transgender
women in their sample experienced discrimination at least once or twice a week.
It also is important to consider other demographic factors when examining discrimination in TGD samples,
as the framework of intersectionality highlights that discrimination can uniquely arise at the intersection of
identities (Crenshaw, 1989). For instance, TGD people of color (particularly transgender women of color)
generally experience higher levels of discrimination compared to White TGD individuals (James, Brown, &
Wilson, 2017; James et al., 2016). Other aspects of identity may similarly be important to examine, such as
education and income. Some research suggests that individuals who have lower levels of educational
attainment and lower levels of income may experience more discrimination (Bradford, Reisner, Honnald, &
Xavier, 2013). In addition, recent findings show that genderqueer individuals experience greater harassment
and other minority stressors compared to trans men and trans women (Lefevor, BoydRogers,Sprague,&Janis,
2019).
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PUCKETT ET AL.
This discrimination reflects a culture of stigma toward TGD people rooted in the systemic oppression of gender
minorities (Hughto White et al., 2015; Restar & Reisner, 2017). Exemplifying the connections between individual
experiences of stigma and the broader sociopolitical context, concerns about gender minority stigma have
increased for TGD individuals following the 2016 presidential election according to selfreports. For instance,
research has shown that TGD people report increased exposure to hate speech, discrimination, and violence since
the election (Veldhuis, Drabble, Riggle, Wootton, & Hughes, 2018). Other research has similarly found increased
levels of stress (Gonzalez, Ramirez, & Galupo, 2018), fear, and anxiety after the election, along with greater levels of
worry about employment protections and safety (Brown & Keller, 2018). The 2016 election has been a particularly
notable event, but it is important to acknowledge the rise in legislation targeting the rights of gender minorities
even before thissuch as the increased number of bills that sought to restrict TGD peoples access to public
restrooms (Wang, Solomon, Durso, McBride, & Cahill, 2016). Given the current sociopolitical context in the United
States, the extreme rates of discrimination experienced by gender minorities, and the recent increased concern
about experiencing discrimination for TGD individuals, it is critical that we learn more about the manner in which
discrimination impacts psychological distress among this community.
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DISCRIMINATION AND PSYCHOLOGICAL DISTRESS
TGD individuals who experience discrimination have elevated psychological distress across a range of outcomes.
Exposure to discrimination has been linked to higher rates of depression (Barzagan & Galvin, 2012; Bockting, et al,
2013; Dispenza, Watson, Chung, & Brack, 2012), anxiety (Bockting et al., 2013), and suicidality (ClementsNolle,
Marx, & Katz, 2006; Staples, Neilson, Bryan, & George, 2018; Testa et al., 2017). In addition, the association
between discrimination and psychological distress may be even stronger for TGD people with low to moderate
levels of peer supports compared to those with high levels of support from peers (Bockting et al., 2013).
Discrimination also is associated with greater internalized stigma and greater expectations of rejection in the
future (Watson, Allen, Flores, Serpe, & Farrell, 2019), showing that this minority stressor also impacts how TGD
people understand and relate to themselves as well as their personal views for their futures.
In addition to negative health outcomes as a result of this stressor, experiences of discrimination broadly impact
overall wellbeing. For instance, discrimination in workplace settings has been associated with higher rates of
unemployment (James et al., 2016), lower socioeconomic status (Mizcock & Mueser, 2014), and a wide range of
economic challenges (Mizock & Hopwood, 2018). When faced with experiences of constant discrimination and
violence, TGD individuals feel exhausted, develop a concern about their safety, and may begin to anticipate
rejection or avoid settings where they either have or could encounter marginalization (Puckett, Cleary, Rossman,
Mustanski, & Newcomb, 2018; Rood et al., 2016). For instance, many TGD youth fear stigma from their medical
providers (Fisher, Fried, Desmond, Macapagal, & Mustanski, 2018) and TGD individuals who encounter
discrimination in health care settings may be more likely to avoid or delay seeking treatment (Glick et al., 2018).
This prior research shows that discrimination has implications for many aspects of TGD peoples lives.
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COPING WITH DISCRIMINATION
According to minority stress theory, specific ways in which TGD individuals cope with stigma may mitigate the
effects of these stressors, making this an important area of study (Testa, Habarth, Peta, Balsam, & Bockting,
2015). As stated in Lazarusmore general work on coping and stress, coping refers to the ongoing cognitive
and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or
exceeding the resources of the person,(Lazarus, 1993, p. 237). The relationship between stress and coping is
dynamic in nature and represents a process through which people are able to change their emotional states
PUCKETT ET AL.
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(Folkman & Lazarus, 1988; Lazarus, 1993). The ways people cope (i.e., coping behaviors/reactions) may have
either positive or negative impacts on their physical or mental wellbeing. As found by Folkman and Lazarus
(1988), some coping strategies (e.g., problemsolving) may reduce distress or produce some improvement in
ones mental state, while others (e.g., internalization of blame) may be associated with greater distress. Coping
strategies such as internalization or substance use also may exacerbate some stressors or may fail to buffer the
effectsofstresslongterm (Folkman & Moskowitz, 2004). In this study, we conceptualized the different ways of
coping we examined as approachoriented (e.g., education and advocacy, resistance) and detachment/
withdrawaloriented (e.g., drug/alcohol use, detachment, internalization) to recognize that different forms of
coping may have different outcomes.
Although the effects of genderrelated discrimination have begun to be more widely studied, less is known
about the coping strategies of TGD individuals. A recent systematic review of the literature on social stress among
TGD people found that of the 77 studies reviewed, 38.96% (n= 30) focused specifically on experiences of
discrimination on the basis of gender identity, which was the most studied minority stressor (Valentine & Shipherd,
2018). By contrast, only 6.49% (n= 5) examined coping abilities or strategies (Valentine & Shipherd, 2018). These
studies and others on coping are only beginning to shed light on the ways TGD people manage stressors. Identifying
the coping strategies that promote the most positive outcomes for TGD people in the face of discrimination can be
useful from a clinical perspective, making this an important area of study. This line of research can help to bolster
resilience (Matsuno & Israel, 2018) and positive outcomes for TGD people.
This existing literature either has focused broadly on coping with minority stress (i.e., not explicitly focused on
discrimination) or has focused on specific forms of coping rather than a range of potential coping responses. For
instance, a study examining anxiety and depression symptoms among TGD individuals found no significant
associations with facilitative coping, but avoidant coping strategies were a mediator of the association between
TGD identity development and overall distress (Budge et al., 2013). White Hughto, Pachankis, Willie, and Reisner
(2017) also examined avoidant coping and found this type of coping mediated the association between
victimization (conceptualized as discrimination, violence, and assault) and depressive symptoms among TGD
individuals. Support for the role of approachoriented coping strategies is more limited. For instance, although
collective selfesteem has been associated with positive psychological outcomes for transgender women (Sánchez
& Vilain, 2009), collective action (e.g., engaging with a minority community through social activism) has not been
found to buffer the effects of discrimination on psychological distress (Breslow et al., 2015). In addition, TGD
individuals who utilize both high levels of functional and dysfunctional coping strategies have significantly worse
mental health outcomes compared to TGD individuals with low levels of dysfunctional and functional coping
strategies and TGD individuals with high functional and low dysfunctional coping strategies (Freese, Ott, Rood,
Reisner, & Pantalone, 2018).
Although much of the prior research has focused on coping broadly with gender minority stress, as
discussed by Ngamake, Walch, and Raveepatarakul (2016), there are advantages to using measures of coping
that are specific to a given stressor (in this case, discrimination). Widely used, broad scales may only capture
the ways people cope with stress generally and may not provide the most accurate information for how
individuals cope in response to gender minority stressors. In the case of TGD individuals coping with
discrimination, responses may include more approachoriented strategies, such as providing education (Nadal,
Davidoff, Davis, & Wong, 2014), confrontation, using resources (e.g., social support, activitybased coping; Bry,
Mustanski, Garofalo, & Burns, 2017), seeking out people and places that would be accepting (Budge, Chin, &
Minero, 2017), or engaging in social activism. TGD people may also react to discrimination by coping with
detachment/withdrawal strategies, such as avoiding potentially hostile environments, emotionally detaching,
or isolating from others (Mizock & Mueser, 2014). It is important to note that these detachment/withdrawal
strategies can also be effective and selfprotective when experiencing marginalization. Although this range of
responses exists, research has yet to fully examine multiple types of responses to discrimination
simultaneously in TGD samples.
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CURRENT STUDY
In the current study, we sought to better understand the association between discrimination and psychological
distress (anxiety and depression) for TGD individuals. To do so, we first evaluated how common various forms of
discrimination were. Following this, we explored how demographic factors (gender, race/ethnicity, and income) may
relate to experiences of discrimination given prior research showing subgroup differences (e.g., Bradford et al.,
2013). We hypothesized that people of color and participants in the lowincome group would experience higher
levels of discrimination compared to other participants. We also provide descriptive information on the
associations between discrimination, coping, and symptoms of anxiety and depression. We hypothesized that
higher levels of discrimination would be associated with higher levels of anxiety and depression symptoms and took
an exploratory approach to the coping variables given the limited research in this area.
Lastly, we took two approaches to examine coping in relation to discrimination. In the first approach, we
conducted multiple mediation analyses to identify the ways of coping that might help explain the associations
between discrimination and psychological distress in TGD individuals. We specifically examined indirect effects
because we assessed coping in response to discrimination and thus were exploring what types of reactions to
discrimination may help explain its links with anxiety and depression. This is in line with othersconceptualizations
of coping in other marginalized groups as mediators of the association between marginalization and mental health
(e.g., racial minorities: Alvarez & Juang, 2010; sexual minorities: Ngamake et al., 2016). In the second approach, we
examined whether the various coping responses moderated the association between discrimination and mental
health to assess whether the coping strategies may buffer or exacerbate the effects of discrimination. This latter
approach aligns with other conceptualizations of coping as representing variables that may influence the
association between stigma and health outcomes (Testa et al., 2015). Given the limited research on coping in TGD
samples, we took an exploratory approach to these analyses rather than being driven by specific hypotheses about
which coping variables would mediate or moderate the association between discrimination and symptoms of
anxiety and depression.
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METHOD
5.1
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Participants
Participants were recruited to participate in an online study of minority stress and health for TGD individuals. A
total of 861 individuals accessed the online survey after being sent a unique link to the study upon qualifying
through a screener questionnaire. After opening the link, 166 respondents were disqualified from the online study
due to a variety of reasons: not answering any questions (n= 26), not answering consent comprehension questions
correctly (n= 71), not answering any questions beyond the consent comprehension questions (n= 48), and a variety
of other reasons (n= 21; e.g., not meeting inclusion criteria, not answering questions beyond demographics,
duplicate IP addresses).
This resulted in a final sample of 695 participants. On average, participants were 25.52 years old (standard
deviation = 9.68; range 1673 years). The sample reported a diverse range of gender identities, with about half of
participants identifying as either transgender men (30.4%) or transgender women (16.6%), and the other half
reporting identities such as genderqueer, nonbinary, and other options. A total of 55 participants indicated that
their gender was not listed in the survey options. Examples of written responses for these participants included:
genderflux,”“I dont even know if I have one [a gender] or not,”“neutrois,and genderfluid.Most participants
were White (75.7%) with low levels of annual income (51.4% earned less than $10,000 a year). The most frequently
reported sexual orientations were queer (25%) and pansexual (18.7%). A full description of demographic
information for the sample is available in Table 1.
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TABLE 1 Sample demographics
Characteristic n (%)
Gender identity
Transgender man 180 (25.9)
Transgender woman 105 (15.1)
Woman 10 (1.4)
Man 31 (4.5)
Genderqueer 87 (12.5)
Nonbinary 132 (19)
Agender 66 (9.5)
Androgyne 7 (1)
Bigender 22 (3.2)
Option not listed 55 (7.9)
Sex assigned at birth
Female 534 (76.8)
Male 156 (22.4)
Difference of sex development
Unsure 124 (17.8)
Yes 20 (2.9)
No 551 (79.3)
Sexual orientation
Queer 174 (25)
Pansexual 130 (18.7)
Bisexual 106 (15.3)
Gay 62 (8.9)
Asexual 100 (14.4)
Heterosexual 38 (5.5)
Lesbian 35 (5)
Option not listed 50 (7.2)
Race/ethnicity
White 526 (75.7)
Black/African American 13 (1.9)
American Indian or Alaska Native 1 (0.1)
Native Hawaiian or other Pacific Islander 0
Asian 21 (3)
Latino/a 25 (3.6)
Option not listed 8 (1.2)
Multiracial/multiethnic 98 (14.1)
Education
Less than high school diploma 91 (13.1)
High school graduate or equivalent 88 (12.7)
Some college education, but have not graduated 228 (32.8)
Associates degree or technical school degree 52 (7.5)
Bachelors degree 160 (23)
Masters degree 63 (9.1)
Doctorate or professional degree 13 (1.9)
Income
Less than $10,000 357 (51.4)
$1019,999 112 (16.1)
$2029,999 59 (8.5)
$3039,999 49 (7.1)
$4049,999 39 (5.6)
$5069,999 36 (5.2)
$7099,999 29 (4.2)
Over $100,000 11 (1.6)
Note: There were five participants with missing data on the question asking about sex assigned at birth, and three
participants with missing data about their race/ethnicity and income. The classification of manand womanrefer to trans
men and trans women respectively, as there were no cisgender individuals in the sample. These options were provided for
participants who do not identify with the prefix of transfor their gender identities.
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5.2
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Procedures
The data presented here were derived from a broader study with two distinct components: (a) a daily diary study of
minority stress, substance use, and sexual health, and (b) a onetime survey administered to individuals who did not meet
inclusion criteria to receive the daily diaries. Participants first completed a brief screener questionnaire to determine which
component of the study they would be asked to complete. Participants had to meet all of the following criteria to be
included in the daily diary section: be between 16and 40year old; identify as trans men, trans women, genderqueer, or
nonbinary; live in the United States; had sex in the past 30 days; and either binge drank or used substances in the past 30
days. Anyone who did not meet all of these criteria, but was at least age 16 and older, trans or gender diverse, and lived in
the United States, was provided the option to participate in the onetime survey. The data presented in this manuscript are
specifically from participants in the onetime survey only and this does not include any participants from the daily diary
portion because some of the measures did not overlap across these studies.
This study was informed by a transgender community advisory board (CAB) that was comprised of local TGD
individuals. The CAB met weekly for a month before data collection and periodically after data collection began.
The CAB provided feedback about the focus of the study and the relevance and cultural sensitivity of the study to
their own lived experiences. In addition, the CAB provided comments on the measures included in the study,
recruitment materials, and retention methods. The inclusion of community members throughout the research
process, both on the research team and the CAB, helped to ensure the sensitivity of the research study to the
unique needs of this marginalized community (Singh, Richmond, & Burnes, 2013).
Recruitment of participants in the study took place across a variety of outlets including Facebook, Twitter, Tumblr, and
other social media sites, as well as through community organizations that serve the TGD community and via flyers at
community events. Participants provided their consent/assent to participate in the study, which was approved by the
Institutional Review Board of the primary investigators institutions with a waiver of parental permission for participants
ages 1617year old under 45 CFR 46.408(c). Participants who completed the onetime survey received a $5 Amazon gift
card, with the exception of the first 200 participants (funding was not available when these individuals participated).
We took several steps to ensure the quality of the data collected in this online survey: (a) participants had to
complete the screener questionnaire to be considered for the study and their responses were examined for
duplicate identifying information; (b) all email addresses were examined to identify any suspicious or duplicate
email addresses; (c) each survey was administered using a unique link that could only be used once; (d) IP addresses
were examined to identify any potential duplicate responses; (e) the survey platform included survey protection
options that prevented the survey from being taken multiple times by the same user, including the screener
questionnaire; (f) the survey software included a CAPTCHA to inhibit programmed responses; and (g) participants
answered a series of three questions to assess their understanding of the study (consent comprehension questions)
and had to answer all three correctly to move forward in the study. These comprehension questions also helped to
disqualify participants who were potentially being careless or randomly responding.
5.3
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Measures
5.3.1 |Demographics
Participants answered a series of questions about their age, gender, sex assigned at birth, any difference of sex
development, sexual orientation, race/ethnicity, income, employment, and education. Table 1 provides an overview
of the sample demographics, including the response options for these questions.
5.3.2 |Discrimination
Based on previous work (Testa et al., 2015), we utilized five items as an index of exposure to various types of
discrimination in the areas of medical and mental health treatment, access to public restrooms, identity
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documentation, housing, and employment. For each question, participants indicated whether each form of
discrimination never happened, or if it happened before the age of 18,after the age of 18, and within the last year.
Participants were allowed to indicate multiple response options (e.g., they could report that the experience
happened within the last year and after the age of 18). We calculated a total score for the items participants
reported encountering over the past year to reflect more recent exposure to these minority stressors. This index
has been found to be valid in prior research (Testa et al., 2015).
5.3.3 |Coping with discrimination
The 20item version of the Coping with Discrimination Scale (Ngamake, Walch, & Raveepatarakul, 2014; Wei,
Alvarez, Ku, Russell, & Bonett, 2010) was used to measure ways of coping with exposure to discrimination. This 20
item version of the scale contains the same factor structure as the original scale, with evidence of good reliability,
and construct validity (Ngamake et al., 2014). Subscale scores were calculated to reflect the Education and
Advocacy Subscale (i.e., trying to inform others and create social change; e.g., I try to educate people so that they
are aware of discrimination.), Detachment Subscale (i.e., disconnection from the stressor and other supports; e.g.,
Ive stopped trying to do anything.), Drug and Alcohol Use Subscale (i.e., use of alcohol or drugs to manage the
effects of discrimination; e.g., I try to stop thinking about it by taking alcohol or drugs.), Resistance Subscale (i.e.,
confrontation of individuals engaging in discrimination; e.g., I respond by attacking othersignorant beliefs.), and
Internalization Subscale (i.e., blaming ones self for the discrimination; e.g., I wonder if I did something to provoke
this incident.). This scale has been used in other marginalized groups, such as racial minorities and sexual
minorities (e.g., Ngamake et al., 2014; Wei et al., 2010). We extend the use of this scale to gender minorities given
that it has been useful across other populations. Due to the structure of this scale, the individual items did not need
modification for use in a TGD sample and were retained in their original format. In the current study, each subscale
showed acceptable to high Cronbachs alpha levels (Education and Advocacy = 0.89; Detachment = 0.75; Drug and
Alcohol Use = 0.96; Resistance = 0.76; Internalization = 0.93) and higher scores on each subscale indicated more
engagement in that form of coping with discrimination.
5.3.4 |Psychological distress
The study included separate measures of depression and anxiety symptoms. Depression was measured using a
short form (eight items) of the PatientReported Outcomes Measurement Information System (PROMIS)
Depression scale (Cella et al., 2011). On this measure, participants reported their symptoms of depression (e.g.,
feeling worthless, helpless, or sad) over the past 7 days. Anxiety was measured using a short form (seven items) of
the PROMISAnxiety scale. On this measure, participants reported their symptoms of anxiety (e.g., feeling
fearfulness, tense, or worried) over the past 7 days. Response options on both scales ranged from Never (1) to
Always (5). To calculate scores on these measures, initially, a raw score was computed and then converted to T
scores, which standardized the scores against national norm data. The Cronbachs alpha in the current study was
0.95 for the depression scale and 0.94 for the anxiety scale. Both of these measures were originally developed and
tested with a large sample of over 20,000 individuals representative of the general population in the United States.
These scales have demonstrated high levels of reliability and validity (Cella et al., 2011).
5.4
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Statistical analyses
All analyses were conducted using SPSS. When calculating all scores, only participants with at least 80% of data for
each measure were retained. On the scales included in our analyses, the amount of missing data ranged from 1.2 to
3%. First, we conducted descriptive analyses to describe the sample and the variables of interest. Following this, we
explored how gender, race, and income may be associated with discrimination. To do so, we constructed
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dichotomous variables for gender (trans men and trans women compared to participants from all other gender
groups), race/ethnicity (White participants compared to participants of color; limited to a dichotomous variable due
to sample sizes), income (participants whose income was less than $20,000 a year compared to participants with an
income higher than this), and a variable that combined race/ethnicity with income (participants of color who earned
less than $20,000 a year compared to all other participants due to small cells). We also created a variable that
combined race/ethnicity and gender to produce the following groups: trans men and women who were people of
color, trans men and women who were White, other gender groups who were people of color, and other gender
groups who were White. We then performed χ
2
analyses for each item on the discrimination scale to assess
whether there were significant group differences.
After these initial analyses, we conducted correlational analyses to understand the associations between study
variables. We then conducted multiple mediation analyses using Model 4 in the PROCESS SPSS macro to assess
indirect effects (Hayes, 2013). For the mediation, the five subscales of the coping with discrimination measure were
entered simultaneously as mediators of the association between discrimination and psychological distress (with
separate analyses for depression and anxiety). These regressions were conducted using biascorrected
bootstrapping with 5,000 samples with 95% confidence intervals (CIs). Lastly, we conducted a series of moderation
analyses using Model 1 of the PROCESS SPSS macro to assess whether there were significant interactions between
discrimination over the past year and the various coping strategies in predicting psychological distress. For each of
these moderation analyses, we controlled for the other coping strategies that were not entered as a moderator. The
interaction terms were created using meancentered variables.
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RESULTS
The degree to which participants reported experiencing discrimination over the past year varied across the specific
items, although the vast majority (76.1%) of participants who responded to these questions reported at least one
form of discrimination. Over the past year, 24% of participants had encountered discrimination in medical or
mental health treatment, 58% had encountered discrimination related to public restrooms, 41.7% had encountered
discrimination in obtaining identity documents that matched their gender identity, 11.4% had experienced
discrimination related to housing, and 13.4% experienced discrimination associated with finding or keeping
employment or receiving promotions at work. Less than a quarter of participants (23.9%) who responded to these
items reported no exposure to discrimination over the past year.
There were not any significant differences between trans women and trans men compared to all other gender
groups for experiences of discrimination over the past year (χ
2
= 0.15 to 3.60; all p> .06). There were not any
significant differences between racial/ethnic groups for any of the discrimination items (χ
2
= 0.001 to 1.54; all
p> .25). The income groups did differ in regard to access to public restrooms (χ
2
[1, N= 674] = 6.10; p< .05), with a
greater percentage of participants in the <$20,000 income group reporting difficulty accessing public restrooms
compared to participants who reported incomes greater than this (62.8% and 52.8%, respectively). However, the
income groups did not differ on any of the other discrimination items (χ
2
= 0.17 to 1.93; all p> .19). There also were
no significant differences between the groups regarding experiences of discrimination when examining the
intersection of race/ethnicity and gender (χ
2
2.14 to 6.94; all p> .07). When examining the intersection of race/
ethnicity and income, there were no significant differences between the groups for any of the discrimination items
(χ
2
= 0.002 to 0.73; all p> .35).
Means, standard deviations, and correlations between study variables are reported in Table 2. Participants in
this study reported on average, depression and anxiety symptoms that were over one standard deviation above the
population mean on these measures. Experiencing greater past year discrimination was associated with more
symptoms of depression and anxiety (r= 0.23, 0.26 respectively; p< .001). Participants who experienced zero
discrimination events had depression scores of 57.25, which increased to 60.95 for those who encountered one
PUCKETT ET AL.
|
9
type of discrimination over the past year, 61.25 for those who encountered two types of discrimination over the
past year, and 63.61 for those who encountered three or more types of discrimination over the past year. In terms
of anxiety, participants who experienced zero discrimination events had anxiety scores of 59.62, which increased to
63.60 for those who encountered one type of discrimination over the past year, 64.10 for those who encountered
two types of discrimination over the past year, and 67.27 for those who encountered three or more types of
discrimination over the past year. In addition, experiencing greater past year discrimination was positively
associated with all forms of coping measured, except drug and alcohol use.
Overall, participants reported using education and advocacy the most to cope (rated on average in the
sometimesto oftenrange), followed by internalization (rated on average as sometimes), detachment (rated on
average as sometimes), resistance (rated on average in the a littleto sometimesrange), and drug and alcohol
use (rated on average in the neverto a littlerange). Furthermore, forms of coping seemed to coalesce into the
approachoriented and detachment/withdraworiented strategies. For instance, individuals with higher levels of
coping via education and advocacy reported less coping via detachment (r=0.25; p< .001) but higher levels of
coping via resistance (r=0.42; p< .001). Individuals with higher levels of coping via detachment reported more
coping via drug and alcohol use (r= 0.17; p< .001) and coping via internalization (r= 0.37; p< .001).
Certain forms of coping also emerged as significantly associated with depression and anxiety. More specifically,
depression and anxiety symptoms were positively associated with coping via detachment (r= 0.42, 0.32,
respectively; p< .001), coping via drug and alcohol use (r= 0.21, 0.18, respectively; p< .001), and coping via
internalization (r= 0.41, 0.34, respectively; p< .001). In contrast, there was not a significant association between
depression or anxiety and coping via education and advocacy and coping via resistance. Given these correlations,
we were interested in understanding how participants who minimally engaged in each type of coping (scoring a2,
or a little like meor less) compared to those who more often used these coping strategies (scoring a4,oroften
like meor greater). Participants who reported using each type of detachment/withdraworiented strategy in the
higher range had higher levels of depression and anxiety symptoms (see Table 3). Most notably, participants who
reported high use of detachment as a coping strategy had a 21.89% higher score on the depression measure and a
17.21% higher score on the anxiety measure compared to participants who reported low use of detachment. In
terms of approach orientated coping strategies, there were not any statistically significant increases in depression
and anxiety when comparing participants in the low and high categories, however, it is worth noting that there
were still increased symptoms in those who reported high use of these coping strategies (i.e., education and
advocacy, resistance).
TABLE 2 Sample means, standard deviations, and correlations of study variables
M(SD) 12 3 45678
1. Past year transdiscrimination 1.52 (1.28)
2. Copingeducation and advocacy 3.81 (1.20)
A
0.14**
3. Copingdetachment 2.96 (1.02)
B
0.10** 0.25**
4. Copingdrug and alcohol use 1.76 (1.16)
C
0.06 0.03 0.17**
5. Copingresistance 2.53 (1.05)
D
0.12** 0.42** 0.08* 0.07
6. Copinginternalization 3.12 (1.45)
E
0.19** 0.03 0.37** 0.19** 0.003
7. Depression T score 60.52 (9.69) 0.23** 0.02 0.42** 0.21** 0.06 0.41**
8. Anxiety T score 63.39 (10.24) 0.26** 0.07 0.32** 0.18** 0.06 0.34** 0.64**
Note: Means of the coping subscales that differ in their subscripts are significantly different from one another.
Abbreviation: SD,standard deviation.
*p< .05.
**p< .001
10
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PUCKETT ET AL.
Two multiple mediation analyses were conducted to understand what types of coping responses might help
explain the association between pastyear discrimination and psychological distress. Results from these multiple
mediation analyses are displayed in Figures 1 (depression) and 2 (anxiety). Examining the direct effect in the first
mediation analysis, there was a significant association between pastyear discrimination and depression symptoms
(B= 1.72; standard error = 0.29; 95% CI: 1.16, 2.28), F(1, 640) = 36.32, R
2
= 0.05. This direct association was smaller,
yet still significant when including the coping style mediators in the analysis, supporting a partial indirect effect for
the coping variables. Entering the coping styles into the mediation analysis accounted for a substantial additional
amount of variance in depression symptoms, F(6, 635) = 42.85, R
2
= 0.29. In the context of all coping styles being
included in the model, significant indirect effects were present for coping via detachment (B= 0.24; standard
error = 0.10; 95% CI: 0.06, 0.45) and coping via internalization (B= 0.35; standard error = 0.09; 95% CI: 0.18, 0.54).
This revealed that past year discrimination was related to greater coping via detachment (B= 0.08; p< .01), which
was in turn related to greater symptoms of depression (B= 2.88; p< .01). Similarly, past year discrimination was
related to greater coping via internalization (B= 0.21; p< .01), which was in turn related to greater symptoms of
depression (B= 1.66; p< .01; Figure 1).
The same pattern of results emerged in the analysis focused on anxiety symptoms. Examining the direct effect
in the second mediation analysis, there was a significant association between pastyear discrimination and anxiety
symptoms (B= 2.06; standard error = 0.30; 95% CI: 1.47, 2.66), F(1, 642) = 47.19, R
2
= 0.07. This direct association
was reduced yet remained significant when including the coping style mediators in the analysisagain, supporting a
partial indirect effect. The coping style mediators accounted for a substantial additional amount of variance in
anxiety symptoms, F(6, 637) = 27.16, R
2
= 0.20. In the context of all coping styles being included in the model,
significant indirect effects were present for coping via detachment (B= 0.19; standard error = 0.08; 95% CI: 0.05,
0.36) and coping via internalization (B= 0.28; standard error = 0.09; 95% CI: 0.13, 0.47). This revealed that past year
discrimination was related to greater coping via detachment (B= 0.08; p< .01), which was in turn related to greater
symptoms of anxiety (B= 2.33; p< .01). Similarly, past year discrimination was related to greater coping via
internalization (B= 0.21; p< .01), which was in turn related to greater symptoms of depression (B= 1.33; p< .01).
TABLE 3 Comparison of high/low coping use
Coping variable
Depression Anxiety Depression Anxiety
M(SD)M(SD) % Increase % Increase
Education and advocacy
Low 59.54 (11.42)
A
60.77 (10.68)
A
High 60.79 (9.94)
A
63.96 (10.73)
A
2.10 5.25
Detachment
Low 54.72 (8.66)
A
58.45 (10.15)
A
High 66.70 (8.94)
B
68.51 (9.38)
B
21.89 17.21
Drug and alcohol use
Low 59.35 (9.79)
A
62.41 (10.40)
A
High 64.66 (9.11)
B
67.42 (7.79)
B
8.95 8.03
Resistance
Low 59.64 (10.78)
A
62.39 (10.57)
A
High 61.62 (9.95)
A
64.19 (11.97)
A
3.32 2.89
Internalization
Low 56.48 (8.75)
A
59.70 (9.53)
A
High 65.52 (8.50)
B
67.58 (10.10)
B
16.01 13.20
Note: Low use of a coping strategy was defined as scoring a2,ora little like meor less; high use of a coping strategy was
defined as scoring a4,oroften like meor greater. According to independent samples ttests, means for the low and high
groups in each coping category that differ in their subscripts are significantly different from one another.
Abbreviation: SD,standard deviation.
PUCKETT ET AL.
|
11
Finally, we conducted a series of moderation analyses to assess whether there were significant interactions
between discrimination and each of the forms of coping in predicting depression and anxiety scores while
controlling for other forms of coping. For instance, we examined whether there was a significant interaction
between discrimination over the past year and coping via education and advocacy when predicting depression,
while controlling for coping via detachment, drug and alcohol use, resistance, and internalization. None of these
analyses revealed significant interactions (b=0.29 to 0.26; all p> .20).
7
|
DISCUSSION
The present study investigated the association between discrimination and mental health in a sample of TGD
individuals. Specifically, we explored the relations between discrimination experienced in the past year, use of
FIGURE 1 Coping mediation of the association between pastyear discrimination and depression
FIGURE 2 Coping mediation of the association between pastyear discrimination and anxiety
12
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PUCKETT ET AL.
various coping strategies (education and advocacy, detachment, drug and alcohol use, resistance, and
internalization), and psychological distress (measured via symptoms of anxiety and depression). Notably, a
substantial portion of our sample (76.1%) reported encountering some form of discrimination over the past year.
Exposure to discrimination did not differ across gender groups, racial/ethnic groups, income groups, or in analyses
that examined multiple aspects of identity simultaneously, with the exception of access to public restrooms being
elevated for participants with low incomes. Even though we did not find differences between groups across most of
these analyses, the framework of intersectionality (Crenshaw, 1989) and recent findings (e.g., James et al., 2016)
indicate that future research must continue to examine how the intersections of identities may relate to
discrimination and health outcomes.
As expected, higher levels of discrimination over the past year were positively correlated with symptoms of
anxiety and depression. These findings are consistent with previous research evidencing the negative mental health
impact of experiencing discrimination for TGD individuals (Bazargan & Galvan, 2012; Bockting et al., 2013;
Dispenza et al., 2012; Yang, Manning, van den Berg, & Operario, 2015). We also found that discrimination over the
past year was positively correlated with each of the coping domains, except drug and alcohol use. These results are
similar to previous research in sexual minorities (Ngamake et al., 2014) and suggest that as individuals encounter
greater amounts of discrimination, they engage in a range of coping strategies in their attempts to manage these
stressors.
The types of coping responses TGD participants engaged in when responding to discrimination emerged as an
important consideration in understanding the mental health toll of discrimination. Indeed, depression and anxiety
were significantly positively associated with detachment/withdrawaloriented coping skills (detachment,
internalization, and drug/alcohol use), and not with the approachoriented ways of coping (education/advocacy
and resistance). Thus, when levels of detachment, drug/alcohol use, and internalization were higher, so too were
anxiety and depression. Unfortunately, due to the crosssectional nature of our data, we were not able to assess the
direction of these effects. It is possible that when people have higher levels of anxiety and depression, they will be
more likely to respond to experiences of discrimination in ways that align more to withdrawal, instead of these
coping responses leading to higher levels of depression and anxiety.
It is also worth noting that coping via resistance and education and advocacy were not significantly associated
with psychological distress, but still there were some elevations in depression and anxiety symptoms for
participants who often used these coping strategies. It is possible that there are both costs and benefits to engaging
in these types of coping strategies. For instance, coping with education and advocacy may be empowering, yet also
emotionally taxing (Nadal et al., 2014). TGD individuals also are often called on to be the educators in response to
other peoplesbias (Levitt & Ippolito, 2014), such as when they are asked to explain why othersactions are
oppressive. In our study, education and advocacy was the most frequent form of coping used by participants. It is
possible that this type of request in response to discrimination may not be helping TGD people beyond any cost
that it may have. This is particularly important considering that, although not statistically significant, there were
increased levels of depression and anxiety for participants who reported high use of the approach oriented coping
strategies.
Given the high levels of discrimination and victimization present in the TGD community (Bockting et al., 2013;
Moradi et al., 2016), which TGD people report having increased following the 2016 election (Veldhuis et al., 2018),
further understanding the pathways through which these events impact mental health is necessary. We found that
there were more anxiety and depression symptoms for participants who encountered higher levels of
discrimination, which was partially explained by detaching and internalizing blame. These results likely speak to
the toll of adverse, discriminatory experiences as they accumulate. As discrimination increases, it may become
more difficult to respond with educating others and engaging in advocacy work, possibly because the individuals
resources diminish via the increased burden of discrimination. As these experiences accumulate, coping via
detachment and/or internalization could become more likely, as less energy is available to devote to education/
advocacy and resistance. Similar results have been observed among individuals coping with multiple minority
PUCKETT ET AL.
|
13
stressors (e.g., racism or sexism and heterosexism), who were found to cope through detachment, rumination, or
internalization (Szymanski, Dunn, & Ikizler, 2014). Future research is needed to understand more about how TGD
people make decisions around how to cope with these stressors.
We also found evidence for grouping among coping responses. Participants who reported higher levels of
coping via education and advocacy reported higher levels of resistance and less detachment. TGD individuals
reporting more detachment reported more drug/alcohol use and internalization. These correlations reinforce the
division between coping skills that may be considered approachoriented versus detachment/withdrawaloriented.
Although longitudinal research is needed in this area, it is possible that coping attempts in one category may
promote similar coping strategies. For instance, when individuals internalize blame for discrimination, they may be
more likely to use alcohol or substances to cope. Likewise, when individuals are more resistant in the face of
discrimination, they may be more likely to engage in advocacy as a broader form of resistance. Future research
aimed at learning how these associations form or change over time may provide insights into how to facilitate more
effective coping. In addition, there may be functional and adaptive reasons why people engage in detachment or
withdrawal oriented coping strategies, such as selfprotection from harm. Future research also needs to consider
that strategies that may be viewed within the broader literature as unhelpful may be protective at times.
Even after accounting for coping responses, there remained an association between discrimination and
symptoms of depression and anxiety. This finding speaks to the importance of social change and the need to
decrease discriminatory acts while promoting protections against discrimination. This could be done through
increasing antidiscrimination protections via policies within companies and businesses or housing authorities, as
well as broader statewide and federal policies to protect TGD people from discriminatory acts. It is not enough to
promote adaptation in the face of these stressorsthe stressors themselves must be addressed.
Finally, our lack of significant findings in the moderation analyses is worth mentioning. None of the coping
variables had a significant moderating effect on the association between discrimination and mental health. As such,
these results suggest that neither the approachoriented nor the withdrawal/avoidanceoriented coping strategies
buffered or exacerbated the effects of discrimination on mental health in this sample. Given the nascent status of
coping research with TGD samples, this may indicate a need to expand the types of coping that are examined or a
need to develop measures of coping strategies that may include unique forms of coping utilized in this community.
For instance, qualitative studies have found a variety of TGDspecific coping strategies, such as challenging gender
norms and engaging in behaviors that affirm ones own gender experience (Budge et al., 2017; Mizock & Mueser,
2014), yet these remain relatively unexamined in quantitative studies of coping.
7.1
|
Clinical implications
Although immediate change in the sociopolitical context may be outside an individuals control, modifying, and
changing ones responses to such stressors may be an empowering way of managing oppression. As we have shown
in this study, it is not uncommon for TGD people to encounter discrimination. In fact, approximately three out of
four TGD participants in this study faced some form of discrimination over the past year. Given this, it is important
for therapists to remember that a TGD persons belief that they might encounter discrimination and the associated
anxiety, worry, and fear may actually be an accurate perception of their social environment and not an inaccurate
interpretation or catastrophic thought process (or other such interpretations). This speaks to the importance of
validating these clientsexperiences and acknowledging the realities of the stigma that exist for TGD people, as
otherwise therapists may potentially damage their rapport with clients and invalidate their experiences. Therapists
may be able to help clients for whom anxious or depressive symptoms have started to interfere with their life in
more culturally responsive ways by assisting clients to recognize the function of these emotional experiences and
by validating the struggles of living within a context that systematically oppresses TGD individuals. Therapists may
then be able to help TGD people relate to their symptoms in more empowering ways that assist them in living their
lives authentically and fully.
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PUCKETT ET AL.
In addition to understanding the role of discrimination in TGD clientslives, therapeutic interventions could be
developed to help individuals cope in ways that aid in the reduction of anxiety and depression. As we have shown
here, TGD individuals engage in a range of responses to manage discrimination and it is possible that TGD people
may benefit from support in balancing approachoriented versus withdrawaloriented coping strategies in the face
of ongoing discrimination. It is likely that there are times where it is functional and adaptive to withdraw from a
situationfor example, if someone is in dangerand there may be times where approachoriented strategies may
be the more functional response.
Therapy can also help TGD clients to externalize (as opposed to internalizing) the pain of discrimination. For
example, therapists can aid individuals in placing the blameof discrimination on a societal issue, as opposed to a
problem within themselves (KashubeckWest, Szymanski, & Meyer, 2008; Puckett & Levitt, 2015; Russell & Bohan,
2006). Therapists also can support clients by helping to build resilience in the face of genderbased discrimination,
through skills such as learning to identify negative societal messages, building hope, and bolstering selfesteem
(Matsuno & Israel, 2018; Singh, 2018). It is important to consider resilience factors that have been found to be
useful for TGD individuals specifically, such as selfdefining their identity (Singh, Hays, & Watson, 2015; Singh,
Meng, & Hansen, 2015). In addition, learning coping skills like emotion regulation and mindfulness in therapy may
aid in reducing the impact of discrimination on mood. Indeed, research with African Americans has suggested that
higher levels of mindfulness and emotion regulation skills are a useful buffer against the effects of racism (Graham,
Calloway, & Roemer, 2015; Graham, West, & Roemer, 2013).
7.2
|
Strengths and limitations
The current study offers a number of strengths. In the context of the dearth of literature on TGD people, our study
offers a novel look into the association between discrimination and coping styles, and how these variables relate to
symptoms of anxiety and depression. The use of the Coping with Discrimination scale (Wei et al., 2010) with a TGD
sample extends prior work done with sexual minority individuals (Ngamake et al., 2014). Our results provide vital
insight into the ways TGD people are coping with and being affected by, discrimination. These findings also support
the development of additional research on the impact of discrimination in TGD samples and targeted therapeutic
interventions to support helpful ways of coping.
Our results should also be considered in light of a number of limitations. First, our study was crosssectional in
nature, so directionality and causality cannot be assumed. Likewise, although we conducted a mediation analysis,
the use of crosssectional data inhibits our ability to understand the temporal unfolding of the effects of
discrimination on psychological distress. Although a limitation, we did utilize data that reflected both retrospective
(discrimination over the past year) and current experiences (coping and symptoms of anxiety and depression) to
attempt to address concerns related to conducting crosssectional mediation analyses. Furthermore, given the
scarcity of research on coping for TGD individuals, our crosssectional mediation analyses may still provide
important insights that future longitudinal research can expand upon.
Other limitations of our study relate to the sample, which was limited in terms of socioeconomic status and
race. The sample mostly represented individuals with low incomes, which may be due in part to the socioeconomic
disparities seen in gender minorities (Kenagy, 2005; Xavier, Honnold, & Bradford, 2007) and the age of our sample
(which included 16and 17year olds). Also, our sample was mostly White, limiting the generalizability of our
findings to people of color who identify as gender minorities. As other research has shown, TGD racial minorities
disproportionately experience discrimination compared to their White TGD counterparts (James et al., 2016). Thus,
our results are likely underestimates of the amount of discrimination encountered by TGD people of color, and
more research is needed to understand how coping may vary across racial groups. We also did not include a
measure of discrimination across other aspects of identity, such as race, and future research should include
assessment of a wider array of discriminatory experiences.
PUCKETT ET AL.
|
15
It is also possible that our sample differs in other ways from the larger population of TGD individuals. For
instance, participating in such a study implies that participants selfidentify as transgender and our participants may
have more connection to community groups than other TGD people given the recruitment methods we used. Lastly,
participants who were asked to participate in the daily diary study instead of this onetime survey had to report
active substance use or binge drinking in the last 30 days for inclusion in that study. This may have resulted in lower
levels of drug and alcohol use to cope in the current sample although overall levels of alcohol use and drug/
substance use were similar to that found in the United States Trans Survey (James et al., 2016). Even so, it is
possible that this coping mechanism may emerge as a significant mediator of the association between
discrimination and mental health in other research.
8
|
CONCLUSIONS
Our study confirms previous research noting high levels of discrimination in the TGD community. Our results
provide novel, empirical evidence for the insidious cycle experienced by gender minorities wherein TGD people are
discriminated against, engage in attempts to cope via a range of strategies, and yet still have heightened levels of
anxiety and depression. This should serve as a call for the development of targeted therapeutic interventions to
help TGD people cope with ongoing discrimination in ways that will be more sustainable and empowering, while
also taking social actions to address discrimination that targets TGD people. Ultimately the burden of addressing
discrimination falls on our society as we must develop a context in which TGD people will not be targeted. While
the struggle to develop a more just society continues, developing methods to bolster coping, and reduce mental
health disparities may serve as an act of resistance to the oppression of TGD people.
ACKNOWLEDGMENTS
The project described herein was supported by a grant from the National Institute on Drug Abuse
(1F32DA038557). We thank the members of the Trans Health CAB who assisted with this project for their
time, feedback, and dedicated involvement. We also thank the participants who completed the study for their time.
ORCID
Jae A. Puckett http://orcid.org/0000-0002-8622-2039
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... However, qualitative findings indicate that TNB individuals also engage in five primary unique and TNB-specific facilitative coping strategies. First, TNB individuals may engage with social activism to develop meaning and fight back against cisgenderism, such as educating others about TNB identities, challenging gender norms, and attending protests (Budge et al., 2013;Matsuno & Israel, 2018;Mizock & Mueser, 2014;Puckett et al., 2020;Singh et al., 2011). 2 Second, TNB individuals may engage in mentorship of TNB mentees, which provokes social connection, encourages role modeling, and is exemplified by acts like teaching other TNB individuals about transitioning, helping individuals connect with resources, and supporting others through experiences with discrimination (Budge et al., 2013(Budge et al., , 2017Cerezo et al., 2014;Matsuno & Israel, 2018). Third, TNB individuals engage in community building with other TNB individuals through joining local TNB focused support groups and creating affirming spaces (Budge et al., 2013(Budge et al., , 2017. ...
... This limitation has constrained researchers' ability to understand how specific coping strategies impact mental health. Researchers using cisgender normed and validated measures, such as the Brief COPE (Carver, 1997) or the Ways of Coping Revised (WC-R; Folkman et al., 1986) within TNB samples have demonstrated that avoidant coping is significantly related to both anxiety and depression (e.g., Budge et al., 2013;Freese et al., 2018;Puckett et al., 2020). However, across these studies facilitative coping has yielded insignificant results regarding its relation with mental health outcomes. ...
... Overall, each subscale and total scale score of the TNCM was related to at least half of the outcome measures of mental health. Again, this is an important finding because past quantitative research has found nonsignificant findings for the relations between facilitative coping strategies and mental health outcomes (Budge et al., 2013;Freese et al., 2018;Puckett et al., 2020). This finding points to the necessity of using a TNB-specific measure to capture the unique ways in which TNB individuals cope with gender-related stress to understand the actual impact of these strategies on mental health outcomes. ...
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Trans and nonbinary (TNB) individuals cope with gender-related stress in unique ways that are not captured in existing coping measures. The present research extends prior qualitative research on these unique coping strategies to develop and validate the Trans and Nonbinary Coping Measure (TNCM). The initial developed pool of potential items was presented to two focus groups and five content experts for review. In Study 1 (N = 298), the 166 initial items hypothesized to underly an eight-factor structure were analyzed using exploratory and confirmatory factor analysis (EFA, CFA). Results from the EFA and CFA revealed a six-factor structure as the best fit with 130 items removed. Study 1 also provided preliminary construct and discriminant validity due to significant correlations between the TNCM and an existing measure of coping and nonsignificant relations with a measure of self-motivation. In Study 2 (N = 497), an independent sample of TNB participants was recruited and findings from CFA analysis indicated that the removal of an additional 8 items was statistically optimal. With the removal of these eight items, configural, metric, and partial scalar invariance between TNB gender identity groups was supported. Additionally, results from Study 2 further supported construct and predictive validity through correlations between the TNCM and measures of gender minority stress and mental health outcomes. Finally, Study 3 (N = 35) provided support for test–retest reliability with a third independent sample of TNB participants. Across the studies, the TNCM was found to be a valid measure of TNB specific ways of coping.
... Everyday aspects of being in the public realm, including experiences of stigma and marginalization for TGD people, have changed or were accentuated during the pandemic. Marginalization based on gender identity and/or expression, also known as gender minority stress, contributes to psychological distress and increased risk for poor health (DuBois, 2012;Hendricks & Testa, 2012;Puckett et al., 2020). We focus on findings about how wearing face masks specifically impact experiences of being misgendered (i.e., treated as a gender one is not) from data collected during the height of the COVID-19 pandemic among a diverse sample of TGD people living in Michigan, Nebraska, Oregon, and Tennessee. ...
... These manifest at interpersonal as well as structural levels (Puckett et al., 2022a) including imposing substantial barriers to accessing healthcare (Puckett et al., 2018), high levels of economic hardship and houselessness (James et al., 2016), heightened exposure to violence and discrimination, and other stressors related to gender-based marginalization (Hughto et al., 2015;Stotzer, 2009). These experiences have negative impacts on health and well-being including mental health outcomes such as depression, anxiety, suicidality (Puckett et al., 2020), and heightened risk for embodied effects including chronic physical disease (Brown & Jones, 2016;DuBois et al., 2017DuBois et al., , 2021. As social and economic inequalities have been exacerbated during the pandemic, TGD people also experience associated reductions in income, heightened job loss, and decreased access to health insurance Kidd et al., 2021;Restar et al., 2021). ...
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Introduction Social isolation and reduced access to public life in response to SARS-CoV-2 (COVID-19) challenges health and well-being for many. Marginalized communities, including transgender and gender diverse (TGD) people, have been disproportionally impacted. Experiences of TGD people should be centered in pandemic-related research to better inform policy. Methods A diverse sample of TGD people (N = 158) were recruited from Michigan, Nebraska, Oregon, and Tennessee to participate in the Trans Resilience and Health Study. Participants ranged from 19 to 70 years old (M = 33.06; SD = 12.88) with 27.2% identifying as trans men/men, 26% identifying as trans women/women, and remaining identifying with terms like genderqueer and nonbinary. Thirty percent identified as people of color. Participants completed a monthly COVID-19-related questionnaire April 2020–March 2021 including open-ended questions to learn what contributed to resilience during this time. Thematic analyses of responses enabled identification of salient themes. Results Analyses revealed pandemic-related changes in social experiences of marginalization and mask-wearing. Twenty-six participants mentioned face masks as contributing to resilience while also elaborating the influence of masks on experiences of misgendering. Participants identifying as trans women reported decreased misgendering while trans men and nonbinary participants reported increased misgendering. Conclusions and Policy Implications Mask-wearing helps reduce transmission of COVID-19. For some trans women, masks also reduce the threat of misgendering and possibly other forms of enacted stigma. However, increased risk for misgendering, as noted by trans men in our study, should be considered and increased supports should be provided.
... Finally, a similar lack of focus on the specific ways of coping with gender dysphoria is also present in TNB focused coping research where the typical aim is to understand how TNB individuals cope broadly (e.g. Puckett, Maroney, Wadsworth, Mustanski, & Newcomb, 2020). This broad understanding of TNB coping categorizes actions into facilitative or avoidant strategies, where facilitative coping involves attending to the problem or altering the environment that is causing distress (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986) and avoidant coping involves distancing oneself from the experience of distress or from thinking about distress (Litman, 2006). ...
... Avoidant coping strategies were described by 50% of the sample, which is in alignment with previous studies (e.g. . Often participants noted that suppression was an especially salient coping strategy utilized to reduce the distress of gender dysphoria and its related thoughts and emotions, which has been described in a previous study documenting the effects of societal discrimination on mental health (Puckett et al., 2020). Notably, avoidant coping is often framed negatively, as something that people should change. ...
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Despite recent trans-affirming research centering experiences of gender dysphoria and its relation to psychological outcomes, there is a dearth of research studying the components of experiences of gender dysphoria. This has limited the ability of clinicians to intervene and reduce the distress caused by gender dysphoria. The current study utilized an online qualitative approach based on cognitive-behavioral therapy thought trackers to ask 108 transgender and nonbinary participants four prompts: a) antecedents of gender dysphoria, b) associated thoughts, c) emotions, and e) ways of coping. Analyses of these prompts revealed that gender dysphoria is frequently triggered by body, social, and intrapersonal experiences and is associated with a range of thoughts (e.g. body, gender presentation, medical transition, and self-harm focused) and emotions (e.g. anger, sadness, fear, and suppression) related to experiences of gender dysphoria. Participants noted engaging in both facilitative coping strategies (e.g. mindfulness, gender affirmation, medical transition, social interactions, and cognitive reframes) as well as avoidant strategies (e.g. distraction; suppression; avoid viewing body/self, social interactions, and voice; and identity concealment) to deal with gender dysphoria. Considering the lack of published therapeutic interventions targeting gender dysphoria, the discussion focuses on the ways the current findings can inform clinical practice with TNB individuals.
... 10 Indeed, unique stressors have been identified across numerous studies linking marginalization with mental and physical health. 13,[16][17][18] Marginalization endured by TGD people includes enacted stigma (e.g., discrimination), 19 felt or perceived stigma, 13,20 internalized/ self-stigma, 21 nonaffirmation/misgendering, 16,17,22,23 and identity concealment. 24 Identity concealment is complex and may be a stressor for some people, such as before ''coming out'' and managing misgendering, but may instead be an act of affirmation for others (e.g., someone who is not perceived as TGD choosing not to share their transition history). ...
... Associations are consistently found linking stressors such as discrimination with mental health outcomes, including suicidality, depression, and anxiety. 13,19,25 Increasingly, research is enhancing understandings of TGD resilience 26,27 and factors that protect against the negative health effects of stigma. 28 Key contributors to resilience include identity pride, 13,28 affirmation of one's gender by others, 29 social supports from family, 30,31 and community connectedness 32 to name a few. ...
... Trans people suffer from a double trauma through their identity development and gender affirmation process: gender trauma, due to a bodily experience of discordance and incongruence, and everyday trauma due to rejection, discrimination, and violence (Langer, 2019). Taken together, this double trauma is associated with severe rates of psychopathology, including depression and suicidal behavior (Baams et al., 2013;Bockting et al., 2013;Connolly et al., 2016;Puckett et al., 2019). Experiencing violence and discrimination leads transgender people to direct negative social attitudes toward themselves while at the same time they try to resist the social stigma associated with gender identity (Testa et al., 2015). ...
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This article is a methodological proposal for Body Mapping application in transgender population framed by a phenomenological approach and aimed at exploring the implicit and pre-reflective embodied cues of the experience of discordance between the felt body (the body I am) and the objective body (‘the body I have’) that opens a space in which words do not have easy access to. In order to describe our protocol of phenomenological exploration and application of Body Mapping, we detail the complete process in a single case. It corresponds to a female-to-male participant of 18 years old undergoing hormonal treatment with testosterone for 12 months before engaging in our study. Reflections about the potential of using art-based research methods for accounting of pre-reflective bodily experience of discordance in transgender population are detailed. The combination of the Body Mapping art-based research tool with a phenomenological approach for the study of experience seems promising for studies aimed at exploring experience from an embodied approach. It represents a radical first-person research method in which the images talk by themselves. Furthermore, including the researchers as beholders of the resulting artwork, assuming the role of inter-corporality of the aesthetic bodily resonance as part of the data collection procedure seems innovative but loyal and honest with what an Art-based research paradigm is.
... 14 Rates of discrimination are also higher among transgender individuals than cisgender individuals regardless of racial or ethnic identity. 15 Discrimination based on sexual and gender identity (i.e. lesbian, gay, bisexual, and transgender status) has been linked to a greater likelihood of developing depressive symptom. ...
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Purpose: This study examines the associations between discrimination experiences (types and locations) and care postponement among trans-feminine individuals in the United States. Methods: This secondary, cross-sectional study utilized a subset of the data from the National Transgender Discrimination Survey (n = 2248), specifically for trans-feminine individuals. In this analysis, we examined the relationship between discrimination and primary care postponement. Results: Twenty-six percent (26.25%) of the study sample reported delaying preventive care due to fear of discrimination; 23.98%-46.66% of respondents reported past experiences of discrimination (setting dependent). Discrimination in health and non-health settings and different types of discrimination-being denied services, verbally harassed, or physically assaulted-were all significantly associated with delaying care; respondents reporting discrimination were up to 20 times more likely to postpone care. While discrimination at a health location had the strongest association with care postponement (adjusted odds ratio = 9.65, confidence interval = 7.60-12.24), discrimination in all non-health-related locations was also important. Individuals reporting discrimination in greater numbers of locations and multiple types of discrimination were more likely to postpone care. Conclusion: To promote preventive care-seeking, these results affirm the importance of interventions that promote discrimination-free environments for gender minorities.
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Purpose: Many transgender youth lack access to transgender affirming care, which may put them at risk for HIV. This study explored transgender youth's perceptions regarding encounters with primary care providers (PCPs) related to gender and sexual minority (GSM) identity and sexual health. Methods: Youth ages 14-21 (N = 228; 45% trans masculine, 41% trans feminine, 14% gender nonbinary) completed a survey on GSM identity disclosure and acceptance, gender-affirming services, sexual health attitudes and behaviors, and interactions with PCPs involving GSM identity and concerns about stigma and confidentiality. Results: A factor analysis yielded three scales: GSM Stigma, Confidentiality Concerns, and GSM-Sexual Health Information. Items from the GSM Stigma scale showed that nearly half of respondents had not disclosed their GSM identity to their PCP due to concern about an unaccepting PCP. One-quarter of youth were less inclined to discuss GSM identity and sexual health with their PCP due to concern that their provider would disclose this information to parents; these concerns were greater among adolescents <18 and those not out to parents about their gender identity. Only 25% felt their PCP was helpful about GSM-specific sexual health issues. Youth who were out to parents about their gender identity and had received gender-affirming hormone therapy were more likely to report receiving GSM-specific sexual health information. Conclusions: Transgender youth may not discuss their GSM identity or sexual health with PCPs because they anticipate GSM stigma and fear being "outed" to parents. PCPs should receive transgender-inclusive training to adequately address youths' sexual health needs and privacy concerns.
Article
To date, researchers assessing the role of discrimination in trans peoples’ lives have relied upon measures that were developed and normed on LGB populations, culled specific items from large-scale survey data, or used more generalized measures of discrimination that do not specifically assess the unique forms of discrimination that trans people may encounter. Thus, the purpose of this three-part study was to develop and provide psychometric support for a measure of trans peoples’ discrimination. In Study 1, a five-factor model emerged, which included: Microaggressions and Harassment, Restricted Career and Work Opportunities, Maltreatment in Health Care Settings, Harassment by Law Enforcement, and Bullying and Harassment in Educational Settings. Internal consistency estimates for subscale and total scale scores ranged from acceptable to excellent. Results from Study 2 revealed that a bifactor model provided the best fit to the data, revealing that the scale is essentially unidimensional. In addition, convergent and concurrent validity was supported, demonstrating significant positive correlations with another measure of trans discrimination, internalized transphobia, nondisclosure, negative expectations for the future, psychological distress, and perceived stress. In Study 3, results revealed excellent test–retest reliability up to a three-week period. Collectively, results suggested that the Transgender Discrimination Scale-21 (TDS-21) is a psychometrically sound measure that may be used to advance research on the role of discrimination in trans peoples’ lives.
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Transgender people experience disproportionately high mental and physical health risks. Minority stress theory identifies distal and proximal stressors that contribute to negative mental health outcomes for transgender people, and suggests that resilience factors can buffer the negative influence of these stressors. In this article, we aim to synthesize the psychological literature on resilience strategies among transgender people and position it within the minority stress framework and introduce an adapted model called the transgender resilience intervention model (TRIM). The TRIM suggests that social support, community belonging, family acceptance, participating in activism, having positive role models, and being a positive role model are group-level resilience factors. Self-worth, self-acceptance and/or pride, self-definition, hope, and transition are individual-level factors that promote resilience. Community, group, and individual interventions and their potential influence on resilience are discussed. The model calls for the development of additional interventions aimed at increasing resilience for transgender people.
Article
Objective: To examine health behavior and outcome disparities between transgender, female, and male participants in a national sample of US college students. Participants and Method Summary: Analyses utilized secondary data from 32,964 undergraduate and graduate students responding to the Fall 2013 American College Health Association-National College Health Assessment; 65.8% were female, 0.4% were transgender, 67.9% were white, and 90.4% were heterosexual. Results: Transgender students reported more mental health diagnoses, trauma, and suicidality; experienced more violence and less safety, reported more sex partners and sexually transmitted infections (STIs); higher rates of illicit and non-prescription substance use and binge drinking use while engaging in less harm reduction behavior; and reported more barriers to academic success. Conclusions: There is an established need for college clinicians and health educators to reduce these disparate outcomes once students arrive on campus through professional training and culturally competent campus prevention and intervention efforts to promote health equity.
Article
Transgender and gender non-conforming (TGNC) populations, including those who do not identify with gender binary constructs (man or woman) are increasingly recognized in health care settings. Research on the health of TGNC people is growing, and disparities are often noted. In this review, we examine 77 studies published between January 1, 1997 and March 22, 2017 which reported mental health outcomes in TGNC populations to (a) characterize what is known about mental health outcomes and (b) describe what gaps persist in this literature. In general, depressive symptoms, suicidality, interpersonal trauma exposure, substance use disorders, anxiety, and general distress have been consistently elevated among TGNC adults. We also used the minority stress model as a framework for summarizing existing literature. While no studies included all elements of the Minority Stress Model, this summary gives an overview of which studies have looked at each element. Findings suggest that TGNC people are exposed to a variety of social stressors, including stigma, discrimination, and bias events that contribute to mental health problems. Social support, community connectedness, and effective coping strategies appear beneficial. We argue that routine collection of gender identity data could advance our understanding mental health risk and resilience factors among TGNC populations.
Article
The outcome of the 2016 US presidential election has raised concerns in the gay, lesbian, bisexual, transgender and queer (GLBTQ) communities nationwide. Utilizing an online survey, we queried GLBTQ individuals about the election outcome and specifically their reactions and experiences from Donald Trump's presidential victory and their interactions with family members who casted a vote different from themselves. Findings revealed that the majority of participants (82%) voted for Democratic presidential nominee, Hillary Clinton. Participants reported that the 2016 election results were stressful and in some cases created interpersonal tension between family, friends, and coworkers. They feared that recent gains like marriage equality and healthcare access would be compromised. Despite these stressors and fears, participants also shared what has allowed them to cope and maintain hope following the election. Implications for mental health professionals offering support to GLBTQ individuals as they face the uncertainty of President Trump's agenda are discussed.