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129
Journal of Mental Health Counseling
Volume 45/Number 2/April 2023/Pages 129–146/https://doi.org/10.17744/mehc.45.2.03
Mental Health Disparities Among
Cisgender, Transgender, and Gender
Nonconforming College Students in
the United States
Priscilla Rose Prasath1, Sabine Lohmar1, Whitney Zahar Rich1,
Emma Elizabeth Dalan1, and Justine K. James2
1 Department of Counseling, University of Texas at San Antonio
2 Department of Psychology, Sri C. Achutha Menon Government College
Compared to cisgender men and women, transgender and gender nonconforming
(TGNC) individuals receive very littl.e attention on their experiences related to men-
tal health. This study examines gender differences in mental health-related outcomes
and their relationship to mental illness diagnoses, psychological service utilization,
help-seeking attitudes, and overall health among students attending universities in
the United States. A survey of 1,034 college students indicated psychological health
significantly varied by gender such that mental health-related outcomes, mental
illness diagnoses, and psychological service utilization were worse for TGNC individ-
uals than for cisgender women or men. These healthcare outcomes were also reported
to be worse for cisgender women than for cisgender men, except for resilience, loneli-
ness, and overall health, for which TGNC participants reported worse outcomes, but
cisgender men and women did not differ. Implications for mental health counselors
and recommendations for future research are provided.
Priscilla Rose Prasath https://orcid.org/0000-0003-1045-210X
We have no conflicts of interest to disclose.
The opinions, findings, and conclusions presented in this article are those of the authors and are
in no way meant to represent the corporate opinions, views, or policies of the American College Health
Association (ACHA). ACHA does not warrant nor assume any liability or responsibility for the accuracy,
completeness, or usefulness of any information presented in this article/presentation.
Correspondence concerning this article should be addressed to Priscilla Rose Prasath, Department
of Counseling, 501 West Cesar E. Chavez Boulevard, Durango Building 4.328, University of Texas at San
Antonio, San Antonio, TX 78207. Email: priscilla.prasath@utsa.edu
Mental Health Disparities
RESEARCH
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Mental illness diagnoses are soaring in college students, with lifetime
diagnoses of mental health disorders in students rising from 22% to 36% from
2007 to 2017 (Lipson et al., 2019). College students experience a variety of
stressors that place them at elevated risk for developing mental illnesses, such
as increased academic demands, financial strain, newfound independence,
living away from parents, and changes to social support systems (Wyatt &
Oswalt, 2013). However, the rise in mental illness diagnoses differs by gender
regarding prevalence and type of mental illness such that certain mental
illnesses are more prevalent in men than in women, in women than in men, or
in transgender or gender nonconforming (TGNC) individuals than in cisgen-
der individuals (Oswalt & Lederer, 2017). Women, for example, are more
likely than men to have major depression, panic disorder, and generalized
anxiety (Eisenberg et al., 2013). TGNC individuals are also more likely than
cisgender individuals to experience generalized anxiety, social anxiety, psycho-
logical distress, and depression (Lefevor et al., 2019). Studies have investigated
gender-related differences in the prevalence of mental illnesses; however,
limited research exists on how these diagnoses are correlated with underlying
factors including mental health outcomes such as psychological distress and
stress. The present study adds to the current understanding of gender-related
mental illness disparities by examining mental health-related outcomes and
help-seeking behaviors in a national sample of college students. The findings
inform recommendations for future research as well as therapeutic consider-
ations for mental health counselors working with college students of diverse
gender identities.
MENTAL ILLNESS AMONG COLLEGE STUDENTS
A growing body of literature dedicated to understanding mental health
issues among college students has emerged over recent years and has indicated
a surge of mental illnesses (Castillo & Schwartz, 2013; Cuijpers et al., 2019;
Wyatt & Oswalt, 2013). The development of most mental illnesses in young
adults can be correlated with the developmental junctures that occur when
transitioning to college (Cuijpers et al., 2019). College students typically expe-
rience greater distress and reduced well-being throughout college, with the
first 2 years of college being when students demonstrate reduced psychological
and social functioning, like decreased self-esteem, lack of social support, and
reduced emotional coping skills (Conley et al., 2020).
Many researchers attribute factors of identity, acculturation, sexual orien-
tation, and substance use and other maladaptive behaviors as potential risk
factors associated with increased mental illnesses reported by college students
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(Castillo & Schwartz, 2013; Wyatt & Oswalt, 2013). Moreover, the COVID-19
pandemic has further exacerbated mental health problems in college students
(López Steinmetz et al., 2021; Son et al., 2020), with 71% experiencing more
stress, anxiety, problems with concentration, and worry about a loved one’s
health as well as their own (Son et al., 2020). During the pandemic, students
felt lonelier and had worse overall mental health (Prasath et al., 2021), partic-
ularly those with existing mental illness diagnoses (López Steinmetz et al.,
2021).
As mental illness prevalence rises in college students, there has been an
upward trend in students seeking help, with on-campus treatment usage rising
5.2% from 2007 to 2017 (Lipson et al., 2019). Despite this increase, though,
most students still do not seek help. Approximately 75% of first-year college
students with any mental illness do not seek help (Bruffaerts et al., 2019).
Therefore, there is a growing need to address possible factors contributing to
reduced help seeking and to identify vulnerable groups in college populations
(Castillo & Schwartz, 2013).
GENDER DIFFERENCES IN MENTAL ILLNESS AND
MENTAL HEALTH-RELATED OUTCOMES
Mental illnesses are rising disproportionately in female college students.
A study examining the prevalence of mental illness in college populations
revealed that women had a higher prevalence than men for major depression
(10% vs 7.5%), panic disorder (5.5% vs 2.3%), eating disorder (13.5% vs 3.6%),
suicidal ideation (6.4% vs 6.1%), anxiety (22% vs 15%), and generalized anxiety
(8.7% vs 4.7%; Eisenberg et al., 2013; Lipson et al., 2019; Pedrelli et al., 2015;
Seehuus et al., 2021). Furthermore, women were more likely to experience
distress and lower self-esteem at the start of college, while men were more
likely to lack social support and show worsening emotional coping throughout
college (Conley et al., 2020).
One explanation for the lower prevalence of mental illness among men
is that masculinity acts as a protective factor by lessening an individual’s inter-
personal demands (Moscovitch et al., 2005). At the same time, masculinity
can lead to masculine gender-role stress, or pressure to conform to rigid gender
roles and dysfunctional coping, which are associated with obsessive-compulsive
disorder and agoraphobia (Arrindell et al., 2003). Additionally, men may be
more likely to externalize emotions, which can lead to aggression and impul-
sive and noncompliant behaviors (Rescorla et al., 2007; Rosenfield & Mouzon,
2013). Masculine gender-role identification can also contribute to underre-
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132 Journal of Mental Health Counseling
porting of anxiety symptoms, which may lead to inaccurate reporting of mental
illness in men (Christiansen, 2015).
Women, on the other hand, are more likely to internalize emotions, lead-
ing to withdrawal, loneliness, and depression (Rescorla et al., 2007). Women
are also more likely to ruminate than men, suggesting that women may remem-
ber and report more symptoms of anxiety (McLean & Anderson, 2009). Despite
exhibiting poorer coping skills, such as rumination, women are actually more
likely to seek treatment than men, such that 39% of women report seeking
help compared to only 30% of men (Pedrelli et al., 2015). Men’s decreased
treatment utilization may be in part due to shame, stigma, and parental and
peer norms toward seeking out mental health services (Seehuus et al., 2021).
Mental illness has traditionally been researched in cisgender populations,
leaving unanswered questions about the experiences of individuals of other
gender identities. TGNC individuals are more likely than cisgender individ-
uals to experience minority stress due to their gender in the form of stigma,
prejudice, discrimination, physical violence, alienation, and non-affirmation,
such as not being referred to by their self-identified pronouns (Meyer, 2003).
Nonbinary individuals, for example, can identify as falling outside or between
“female” and “male,” can identify as female or male at different times, and
can also reject or not identify with any gender (American College Health
Association [ACHA], 2020; Budge, 2017). Nonbinary individuals may have
more social anxiety, depression, psychological distress, eating disorders, subju-
gation to traumatic events, self-harm, and suicidality than either cisgender or
binary transgender individuals (Lefevor et al., 2019).
Given the impact that gender-related stressors play in the rise of mental
illness in college students, this study aims to bridge the gap in mental health
clinicians’ and researchers’ understanding of how diverse gender identities
influence mental health-related outcomes and mental illness. Therefore, this
study addresses two research questions: (1) Do gender differences (i.e., between
cisgender men, cisgender women, and TGNC individuals) exist among college
students in the prevalence of mental illness, utilization of psychological
services, and mental health-related outcomes (i.e., psychological distress, stress,
resilience, overall health, and loneliness)? (2) Do mental health-related vari-
ables differentially predict mental illness diagnoses among college students?
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METHOD
Participants and Data Collection
The ACHA (2020) National College Health Assessment–III Fall 2020
(NCHA-III) is a survey that gathers information regarding students’ health.
With approval from the institutional review board, access to survey data was
granted to the team on May 24, 2021. The survey is sent to all students at
participating institutions for voluntary completion and includes data from over
13,373 college students from 22 different postsecondary institutions (ACHA,
2020). Participants included 9,207 (68.8%) cisgender women, 3,629 (27.1%)
cisgender men, and 452 (3.4%) TGNC individuals (i.e., those who reported
being transgender, genderqueer, agender, gender-fluid, intersex, or nonbinary).
Participants who did not respond to any of the gender-related questions (n = 85;
0.6%) or who gave inconsistent responses (e.g., identifying as female at birth,
stating the gender identity of a woman, but selecting “yes” for transgender;
n = 97) were eliminated from the data. The ACHA (2020) categorizes all
non-cisgender individuals as “nonbinary”; however, not all individuals in this
category identify as nonbinary. To more accurately describe this group, the
term TGNC will be used. After cleaning the data for incomplete responses,
there were a total of 346 TGNC individuals. To compare participants across
Table 1 Participant Demographics
Gender identity Female
(cisgender)
Male
(cisgender)
TGNC
n%n%n%
Ethnicity
Asian or Asian American 27 7.8 39 11.3 17 4.9
Black or African American 23 6.6 21 6.1 12 3.5
Hispanic or Latino/a/x 21 6.1 18 5.2 12 3.5
Middle Eastern/North African 0 0 4 1.2 2 0.6
White 236 68.2 229 66.2 241 69.7
Multiracial 32 9.2 31 9.0 55 115.0
Education level
Undergraduate 226 65.3 229 66.2 272 78.6
Postgraduate 58 16.8 52 15.0 38 11.0
Doctorate 58 16.8 56 16.2 29 8.4
Others (non-degree seeking) 4 1.2 8 2.3 6 1.7
Note. TGNC = transgender and gender nonconforming.
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three gender categories, an equivalent number of cisgender women and men
were randomly selected to generate comparably sized groups across cisgender
men, cisgender women, and TGNC individuals. The resampling technique of
SPSS version 28 was used for random selection. The final sample consisted of
1,038 students: 346 cisgender men, 346 cisgender women, and 346 TGNC
individuals (Mage = 23.13 years, SD = 7.23). Ethnicity and education levels can
be seen in Table 1. Sample size adequacy was tested with G*Power version 3.1.
The minimum sample size required to carry out analyses of variance (ANOVAs)
with a moderate effect size, alpha error of .05, and power of .9 is 207. The current
sample size was also found to be sufficient for logistic regression and chi-square
analysis.
Measures
All variables of interest were taken from those included on the NCHA-
III, including scales related to mental illness diagnoses, psychological service
utilization, mental health-related outcomes, and overall health.
Gender
Individuals’ genders were determined by asking three questions: (1) “What
sex were you assigned at birth?” (female, male, or intersex); (2) “Do you iden-
tify as transgender?” (yes or no); and (3) “Which term do you use to describe
your gender identity?” (woman or female, man or male, transwoman, transman,
gender queer, my gender identity is not listed, agender, gender fluid, nonbinary,
or intersex). Individuals are categorized as cisgender female or cisgender male
unless (a) they select yes for one of the other eight response options, (b) their
sex assigned at birth does not match their gender identity, or (c) their gender
identity is anything other than male or female. Individuals assigned intersex at
birth are categorized as their gender identity unless they also answered “yes” to
identifying as transgender (ACHA, 2020).
Mental Illness Diagnoses
Information related to mental illness was taken from multiple questions
that were all nominal such that all response options were either yes or no. The
following question was used to gather participants’ self-reported mental illness
conditions: “Please indicate in which of the following categories you have
another ongoing or chronic condition that has been diagnosed by a healthcare
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or mental health professional” (insomnia, obsessive-compulsive disorder [OCD],
post-traumatic stress disorder [PTSD], depression, bipolar disorder, and anxiety).
Help-Seeking Attitude and Psychological Service Utilization
Help-seeking attitudes were determined from the question “If in the future
you were having a personal problem that was really bothering you, would you
consider seeking help from a mental health professional?” Utilization of
mental health services was assessed with the following questions: “Have you
ever received psychological or mental health services?” and “Within the last 12
months, have you received psychological or mental health services?”
Mental Health Outcomes
Measures of stress were taken using ordinal responses to the question
“Within the last 30 days, how would you rate the overall level of stress you
have experienced?” with responses of no stress (1), low (2), moderate (3), or
high (4). The remaining mental health-related outcomes were measured using
standardized scales including the Kessler Psychological Distress Scale (K6;
Kessler et al., 2002), Connor-Davidson Resilience Scale-2 (CD-RISC2;
Vaishnavi et al., 2007), and UCLA Loneliness Scale–III (Russell, 1996). K6
asks, “During the past 30 days, about how often did you feel ... nervous; hope-
less; restless or fidgety; so sad nothing could cheer you up; that everything was
an effort; worthless?” with response options ranging from none of the time (0)
to all the time (5). The Cronbach’s alpha of the K6 scale was .88 in this study.
CD-RISC2 measures resilience by asking, “Please indicate how much you
agree with the following statements as they apply to you over the last month. If
a particular situation has not occurred recently, answer according to how you
think you would have felt: I am able to adapt when changes occur; I tend to
bounce back after illness, injury, or other hardships.” Responses ranged from
not at all true (0) to true nearly all the time (4). The Cronbach’s alpha of the
CD-RISC2 was .76 in this study. The UCLA Loneliness Scale-III consists of
three items to assess feelings of loneliness and social isolation. The Cronbach’s
alpha of the UCLA Loneliness Scale–III in this study was .82. Lastly, overall
health was measured using the question “How would you describe your overall
health?” with responses of excellent (1) to poor (5). All these scales have strong
psychometric properties (Kessler et al., 2002; Russell, 1996; Vaishnavi et al.,
2007).
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Data Analysis
Statistical analyses were conducted using IBM SPSS version 28. First,
descriptive statistics, chi-square test for independence, and multiple ANOVAs
followed by post hoc analysis with Bonferroni correction were used to examine
associations and make comparisons across the three gender groups regarding
their reported mental illness diagnoses, psychological service utilization,
and mental health-related outcomes. Finally, the predictive role of mental
health-related outcomes on mental illness diagnoses was tested with binary
logistic regression analysis.
RESULTS
In this study, our primary focus was to evaluate whether gender differ-
ences (i.e., between cisgender men, cisgender women, and TGNC individuals)
existed among college students regarding the prevalence of mental illness,
Table 2 Relationship Among Health, Stress, Psychological Distress, Loneliness, and Resilience
Variables M SD 1 2 3 4
1. Overall health 2.50 0.96
2. Stress 3.19 0.72 .368**
3. Psychological distress 9.58 5.60 .471** .601**
4. Loneliness 5.79 1.91 .319** .377** .537**
5. Resilience 5.89 1.51 –.333** –.252** –.442** –.302**
** p < .01.
MENTAL HEALTH DISPARITIES 30
Figure 1
Mental Health-Related Outcomes Among Gender Groups
Note. TGNC = transgender and gender nonconforming.
Note. TGNC = transgender and gender nonconforming.
Figure 1 Mental Health-Related Outcomes Among Gender Groups
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utilization of psychological services, and mental health-related outcomes
(i.e., psychological distress, stress, resilience, overall health, and loneliness).
Correlational analyses conducted to examine the relationship between mental
health-related outcome variables, indicated in Table 2, demonstrate that all
the psychological outcome variables included in the present study were signifi-
cantly related to each other. Psychological distress and stress were the most
significantly correlated variables (r = .601, p < .001). Conversely, stress and
resilience were the two variables that were least associated with one another
(r = –.252, p < .001). Also, as expected, resilience was negatively correlated
with all mental health-related outcome variables (r = –.333 for overall health,
–.252 for stress, –.442 for psychological distress, and –.302 for loneliness;
p < .001).
Error variances among cisgender men, cisgender women, and TGNC
individuals were equal for mental health variables (F = 0.68 for overall health,
2.8 for level of stress, 0.41 for psychological distress, 1.15 for loneliness, and
0.42 for resilience; p > .05). However, covariance matrices were not equal
(F = 2.64, p < .001) to conduct multivariate analysis of variance (MANOVA).
Table 3 Mental Illnesses Diagnoses and Psychological Services Utilization Based on Gender Groups
Mental illnesses and
psychological services
utilization
Women (cisgender) Men (cisgender) TGNC individuals
χ2
n%n%n%
Mental illnesses
Insomnia 23 6.7 16 4.7 55 16.1 30.82**
OCD 29 8.4 15 4.4 45 13.1 16.60**
PTSD 26 7.5 12 3.5 66 19.3 50.79**
Depression 94 27.3 55 16.0 167 48.4 87.48**
Bipolar disorder 7 2.0 7 2.1 28 8.1 21.74**
Anxiety 119 34.4 66 19.4 189 54.9 94.17**
Help-seeking attitude 289 84.0 236 68.4 278 80.8 27.06**
Psychological service (ever) 177 51.2 121 35.1 263 76.5 120.77**
Psychological service
(12 months)
113 32.7 59 17.2 196 57.0 120.96**
Note. TGNC = transgender and gender nonconforming; OCD = obsessive-compulsive disorder;
PTSD = post-traumatic stress disorder.
** p < .01.
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Thus, the variables were analyzed using one-way ANOVAs. The summary of
ANOVA (Figure 1) indicated that mental health variables and overall health
differed based on gender, F(2, 984) = 85.07 for psychological distress, 32.23 for
resilience, 42.35 for loneliness, 63.23 for level of stress, and 51.93 for overall
health; p < .001. Effect sizes (ηp2) ranged from .06 to .14.
Post hoc comparisons using Bonferroni corrections were carried out.
Results indicated that overall health, loneliness, and resilience were similar
among cisgender men and cisgender women (t = 2.24, 1.63, and 2.38, respec-
tively; p > .05). Stress and distress scores were higher for cisgender women
compared with cisgender men (t = 7.38, 3.66, p < .001). TGNC individuals
scored lower than both cisgender men and cisgender women for all variables
(t = 9.73, 7.49 for overall health, t = 11.04, 3.66 for stress, t = 12.68, 9.02 for
psychological distress, t = 8.65, 7.02 for loneliness, t = 7.92, 5.54 for resilience;
p < .001). In particular, across all mental health-related outcomes except over-
all health, loneliness, and resilience, mental health decreased across gender
groups such that outcomes worsened from cisgender men to cisgender women
and then to TGNC individuals.
Furthermore, the pattern of progressively worse mental health-related
outcomes across gender identities (Figure 1) was also present for mental illness
diagnoses and psychological service utilization, excluding bipolar disorder
(Table 3). TGNC individuals reported the highest prevalence of all mental
illness diagnoses, followed by cisgender women and then cisgender men (x2
Table 4 Predicting Mental Illness Diagnosis From Mental Health-Related Outcome Variables
Mental illness
diagnosis
Predictors
R2
General health Stress Psychological
distress
Loneliness Resilience
Wald Exp(β)Wald Exp(β)Wald Exp(β)Wald Exp(β)Wald Exp(β)
Insomnia 1.26 1.15 2.27 1.40 10.23** 1.09 2.75 1.12 0.18 1.03 .12
OCD 0.01 1.01 3.03 1.47 9.82** 1.09 0.12 0.98 0.11 0.98 .08
PTSD 6.12* 1.36 13.56** 2.29 5.44* 1.06 0.22 0.97 0.72 1.07 .14
Depression 2.04 1.13 8.64** 1.51 42.70** 1.14 5.35* 1.11 1.52 1.07 .25
Bipolar
disorder
1.61 1.26 1.79 1.58 8.90** 1.12 0.76 0.92 0.46 1.08 .11
Anxiety 2.80 1.15 24.16** 1.90 21.28** 1.09 0.22 1.02 0.13 0.98 .21
Note. OCD = obsessive-compulsive disorder; PTSD = post-traumatic stress disorder.
* p < .05. **p < .01.
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= 16.60 to 94.17, p < .001). Anxiety was the most frequently reported mental
illness diagnosis across all genders, followed by depression. However, TGNC
individuals reported the greatest breadth of diagnoses such that more than 10%
reported other disorders such as insomnia, OCD, and PTSD, compared with
less than 10% in cisgender men and cisgender women. Bipolar disorder was the
least reported diagnosis across all three groups (2.1% for cisgender men, 2% for
cisgender women, and 8.1% for TGNC individuals).
Consistent with the increased reports of mental illness diagnoses concern-
ing cisgender men, cisgender women, and TGNC individuals, results indi-
cated that utilization of psychological services, excluding help-seeking attitude,
increased according to gender groups, such that TGNC individuals were most
likely to have received psychological services in the last 12 months (57%) or
ever (76.5%; Table 3). This trend continued across cisgender men, cisgender
women, and TGNC individuals, excluding help-seeking attitudes, for which
cisgender women and TGNC individuals were similar (84% and 80.8%,
respectively), and cisgender men were the least likely to seek help (68.4%).
We further evaluated the second research question of how mental
health-related outcomes predicted mental illness diagnoses in college students.
Regarding the mental health-related outcome variables, results indicated that
psychological distress and stress were the most predictive of mental illness
(Table 4). Psychological distress and stress were similar in terms of their
associative strength among all the mental health variables (Table 2), yet they
differentially predicted mental illness (Table 4). Binary logistic regression
analyses indicated that psychological distress predicted all mental health
variables (WT =10.23, p = .001, for insomnia; WT = 9.82, p = .002, for
OCD; WT = 42.70, p < .01 for depression; WT = 21.28; p < .001, for anxiety;
WT = 8.90, p = .003, for bipolar disorder; WT = 5.44, p = .02, for PTSD; Table
4). Conversely, stress was found to be the predictor of PTSD, depression and
anxiety (WT = 13.56, p < .01 for PTSD; 24.16, p < .001, for anxiety; WT 8.64,
p = .003, for depression). General health and loneliness also predicted PTSD
and depression respectively, WT = 6.12, p = .01, for PTSD; WT = 5.35, p < .02,
for depression.
DISCUSSION
The purpose of this research was to examine gender differences among
college students’ reports of mental health-related outcomes, mental illnesses,
utilization of psychological services, and overall health. The present study adds
to the literature by finding evidence for a gender-related trend across mental
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health outcomes, as well as suggesting potential explanations for the gender-
related differences in mental illness rates. Results indicated three main find-
ings. First, mental illness and mental health-related outcomes, excluding lone-
liness, were progressively worse across gender groups, from cisgender men to
cisgender women and then TGNC individuals. The mental illnesses included
in this study were most prevalent in TGNC individuals, followed by cisgender
women and then cisgender men. Additionally, mental health-related outcomes
(psychological distress, stress, overall health, and resilience) worsened from
men to women to TGNC individuals. Both results are consistent with previous
literature demonstrating a trend of worse mental health outcomes in TGNC
individuals versus cisgender individuals and worse outcomes for women than
men (Conley et al., 2020; Lefevor et al., 2019; Lipson et al., 2019; Liu et
al., 2019; Oswalt & Lederer, 2017; Seehuus et al., 2021). This trend may
be explained by exposure to life stressors based on gender norms, which
suggests that gender minorities experience higher rates of mental illness due to
increased exposure to stressors such as harassment and discrimination (Meyer,
2003; Liu et al., 2019). TGNC individuals, for example, are at a greater risk
for experiencing minoritized stress, such as prejudice, stigma, and discrimina-
tion; therefore, they are more likely than cisgender individuals to experience a
greater degree of victimization, isolation, and lack of belongingness on campus
(Lefevor et al., 2019).
Several factors may explain why mental health outcomes were worse
among women than men. Some researchers suggest women are more likely to
ruminate than men (Tompkins et al., 2011) and, as a result, are at a greater risk
of developing mood-related psychological disorders and suffer from heightened
psychological distress (Conversano et al., 2020). Compared to men, women
are more likely to suffer from internalizing mental illnesses such as anxiety
and depression due to increased feelings of self-blame, low self-esteem, help-
lessness, and hopelessness as well as higher levels of caregiving (Rosenfield
& Mouzon, 2013). Lastly, studies show that women report more sadness and
anxiety following stressful events, whereas men report more behavioral arousal
and cravings, suggesting that differences in emotional coping make men and
women susceptible to different mental illnesses (Chaplin et al., 2008).
The second main finding indicated a downward trend in the utilization
of mental health services across gender groups such that it was highest among
TGNC individuals, followed by cisgender women and then cisgender men.
Interestingly, though, help-seeking attitudes deviated from this trend and were
highest in cisgender women and TGNC individuals, followed by cisgender
men. This gap between cisgender men and women is consistent with previ-
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ous research and may be attributed to a lack of reporting by cisgender men
due to shame, stigma, and parental and peer norms, thereby reducing these
men’s use of mental health services (Seehuus et al., 2021). It has also been
found that masculine gender-role identification leads to underreporting of
treatment seeking (Christiansen, 2015). Conversely, TGNC individuals’ and
cisgender women’s help-seeking attitudes may be higher than cisgender men’s
due to their tendency to internalize emotions more often than cisgender men
(Rescorla et al., 2007; Rosenfield & Mouzon, 2013). Lastly, cisgender men
may have had the lowest levels of help-seeking attitudes and treatment seeking
simply because they experienced the lowest prevalence of mental illnesses of
the three gender groups.
The final finding of this study was that mental health-related variables
differentially predicted mental illness diagnoses across all genders. Stress and
psychological distress were strong predictors of OCD, anxiety, and depression,
which is consistent with prior research showing that stress is a predictor of
mental illness diagnoses (Liu et al., 2019). Not surprisingly, given the import-
ant role that stress plays in PTSD, stress was the best predictor of PTSD diagno-
ses (American Psychiatric Association, 2013). Likewise, psychological distress
emerged as the best predictor of insomnia and bipolar disorder. In our study,
psychological distress and stress were found to be the most predictive of mental
illnesses, countering the protective nature of factors such as overall health and
resilience. Therefore, this suggests that when an individual’s distress and stress
threshold is breached, resilience and overall health are no longer protective
against mental illness. This finding conflicts with studies showing that protec-
tive factors, such as resilience, help reduce psychological distress and protect
against negative psychological outcomes (Conversano et al., 2020). However,
research also suggests that the existence of multiple mental health concerns,
including distress and stress, has collective negative effects on mental illness
diagnoses in gender minority individuals (Stall et al., 2008). For individuals
experiencing gender and minority stress, health disparities, compromised social
connections, or distal and proximal stressors associated with gender identity, it
is possible that interventions targeted at reducing negative outcomes would be
more beneficial than attempting to solely bolster positive outcomes (Lefevor
et al., 2019).
Implications for Mental Health Counselors
Results of the present study indicated gender-related differences in
psychological distress and mental illness, suggesting a need for interventions
targeted at reducing life stressors experienced by students who are female and/
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or belong to gender minorities. Systemic interventions are necessary to address
these inequalities. Most importantly, the high prevalence of mental illness
diagnoses in TGNC college students suggests an immediate need for cultur-
ally competent counselors to engage in outreach efforts on college campuses
among this specific population. Our findings call for discourse among mental
health professionals on why TGNC individuals continue to suffer from lower
levels of mental health-related outcomes and higher levels of mental illness
diagnosis, despite their higher likelihood of treatment seeking than any other
gender groups. This calls for evaluating the current practices of counseling
centers to support gender minority individuals. We advocate for training
culturally competent counselors who are equipped to offer creative therapeutic
support in ways that reduce negative stigma around help seeking. Lastly, based
on the present results indicating reduced help-seeking attitudes in cisgender
men, students and counselors may benefit from developing targeted market-
ing campaigns aimed at reducing the stigma surrounding seeking treatment,
particularly to benefit male college students who are suffering from mental
illness concerns.
Despite prior research suggesting that resiliency and other protective
buffers can help protect against the development of various mental health
concerns (Conversano et al., 2020), results in the present study suggest that
when psychological distress and stress are high, resiliency may not be protective
among college students. Therefore, counselors may need to focus attention on
implementing strategies that directly reduce negative mental health outcomes
as opposed to developing positive mental health outcomes such as resiliency.
Given the compounding nature that stress and distress have on mental
illness, students may need more help learning effective skills for coping with
exposure to stressful events (Rosenthal & Wilson, 2016). Moreover, mental
health counselors must educate themselves on the impact that minority stress
has on gender minority individuals and address critical issues such as psycho-
logical distress in treatment.
Limitations and Recommendations for Future Research
There are a few limitations to this study. This research utilized self-
reported secondary data, and the nature of the analyses was cross-sectional
and correlational, wherein causal inferences could not be concluded. Also,
besides cisgender men and women, the third gender group included trans,
genderqueer, and all other TGNC individuals of multiple genders. The
further breakdown of this broad umbrella term, including the differentiation
of TGNC individuals by gender (e.g., male, female, nonbinary), is crucial
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to meaningfully investigate the intricacies of the mental health scenario of
each gender group. Additionally, the complexity of gender identity means
that many individuals may not categorize themselves as any of the gender
identities listed. This complexity makes comparison across gender identities
inherently difficult. Furthermore, in the NCHA-ACHA-III Fall 2020 survey,
there were significantly fewer TGNC individuals than cisgender men and
women. Therefore, to make reasonable comparisons between groups, we
randomly selected the sample for this study without using the entire survey
sample. Additionally, in this study, we identified and evaluated only a few of
the mental illnesses and physical health diagnoses reported by the participants
in the survey. Future researchers may examine other items of the survey that
may offer additional insight into the findings of this study. For example, it may
be argued that cisgender men’s reports of mental illness may not be capturing
the complete picture, as they may be more likely to externalize problems than
women (Rescorla et al., 2007) and, therefore, be susceptible to illnesses such
as conduct disorder or substance use disorder (Rosenfield & Mouzon, 2013).
Moreover, we posit the need for future research efforts to be directed toward
examining the intersection between each specific gender identity and mental
health-related outcomes. This could provide significant insights that may
inform the protective and risk factors for mental illness in these populations.
Lastly, our findings call for the practice-based scholarly community to develop
evidence-based practices for culturally competent counselors to use with
gender minority individuals. Specifically, further research is warranted to exam-
ine why TGNC individuals have the highest prevalence of mental illnesses
despite possessing positive help-seeking attitudes and the highest utilization
of psychological services. This may propel a positive movement within higher
education leadership and administration in the development of comprehensive
policies and the establishment of growth-fostering organizational culture in the
United States.
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