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Research paper
Romantic relationships buffer minority stress in transgender and
non-binary adults: Effects on depressive symptoms and suicidality
Christopher A. Pepping
a,*
, Natasha Belmont
b
, Timothy J. Cronin
b
a
School of Applied Psychology, Grifth University, Australia
b
School of Psychology and Public Health, La Trobe University, Australia
ARTICLE INFO
Keywords:
Transgender
Non-binary
Depression
Suicidality
Minority stress
Relationship involvement
ABSTRACT
Background: Transgender and non-binary (TNB) individuals are at greater risk of mental health concerns relative
to their cisgender peers due to experiences of minority stress. Thus, it is critically important to identify factors
that may be protective and buffer the effects of minority stress. This study examined whether romantic rela-
tionship involvement and quality buffered effects of TNB minority stress on depressive symptoms and suicidal
ideation.
Methods: A large international sample (n =1156) of TNB adults (n =654 partnered; n =502 single) reported on
minority stress experiences, relationship status and quality, and mental health outcomes (i.e., depressive
symptoms and suicidal ideation).
Results: The effects of victimization and rejection on depressive symptoms and suicidal ideation were attenuated
among partnered individuals. However, once relationship quality was considered, the buffering effects of rela-
tionship involvement applied only to those in more satisfying relationships; the stress-buffering effects were not
observed among those in distressed relationships. Of particular importance, general interpersonal satisfaction did
not act as a minority stress buffer, suggesting there may be unique stress-buffering effects of being in a satisfying
romantic relationship on depressive symptoms and suicidal ideation.
Limitations: The cross-sectional nature of the current study precludes denitive conclusions regarding causation.
Conclusions: These ndings suggest that romantic involvement may serve a stress-buffering role for TNB adults,
but only when these relationships are satisfying. Our results have important theoretical and clinical implications,
and further research is needed to investigate the utility of relationship interventions to buffer the effects of TNB
minority stress on depressive symptoms and suicidality.
1. Introduction
1.1. Minority stress and TNB mental health
Transgender and non-binary (TNB) individuals are those whose
gender differs from the sex that was assigned to them at birth, whereas
the term cisgender refers to those whose gender identity is the same as
their birth assigned sex (Matsuno and Budge, 2017). Minority stress
theory describes how the stress of living in stigmatizing environments
undermines mental and physical health (Hatzenbuehler, 2009; Meyer,
2003; Meyer et al., 2008; Testa et al., 2015). Distal minority stressors are
external stigma-events (e.g., discrimination, rejection, and victimiza-
tion), whereas proximal stressors develop in response to distal stressors
(e.g., internalized stigma (or internalized transphobia), and anticipated
stigma) (Hatzenbuehler, 2009; Meyer, 2003; Testa et al., 2015).
TNB individuals experience high rates of stigma, discrimination, and
victimization. For instance, about 70 % of TNB people report having at
least one experience of victimization due to their gender (Boza and
Nicholson Perry, 2014). Similarly, more than 70 % report having
experienced verbal abuse, and a sizeable minority report difculties
* Corresponding author.
E-mail address: c.pepping@grifth.edu.au (C.A. Pepping).
Contents lists available at ScienceDirect
Journal of Affective Disorders
journal homepage: www.elsevier.com/locate/jad
https://doi.org/10.1016/j.jad.2024.06.062
Received 12 March 2024; Received in revised form 7 June 2024; Accepted 17 June 2024
Journal of Aective Disorders 365 (2024) 634–643
Available online 18 June 2024
0165-0327/© 2024 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (
http://creativecommons.org/licenses/by/4.0/ ).
gaining employment (37.9 %), sexual assault or abuse (14.9 %), and
physical victimization (23.6 %) (Bockting et al., 2013). TNB individuals
face stigmatization, discrimination, and victimization across a range of
contexts, including romantic relationships (Perez and Pepping, 2024),
peer-groups (Norris and Orchowski, 2020), workplaces (Bockting et al.,
2013), families (Belmont et al., 2023), and healthcare settings (Cronin
et al., 2023; Rodriguez et al., 2018). Much evidence suggests that such
experiences of minority stress lead to poorer mental health outcomes for
TNB individuals (Bockting et al., 2013; Pellicane and Ciesla, 2022;
Valentine and Shipherd, 2018).
TNB individuals experience poorer mental health outcomes relative
to their cisgender peers (Hill et al., 2021; Warren et al., 2016). For
instance, they are at greater risk of having a diagnosed mental health
condition, such as mood or anxiety disorders (Bouman et al., 2017;
Hanna et al., 2019; Leonard et al., 2015; Witcomb et al., 2018). Rates of
depressive symptoms and depressive disorder among TNB individuals
are substantially higher than that observed in the general population
(Budge et al., 2013; Chodzen et al., 2019; Hanna et al., 2019). Further,
TNB individuals show elevated suicidal ideation and are more likely to
attempt suicide compared to the general population (Adams and Vin-
cent, 2019; Kidd et al., 2023), with over 55 % of TNB adults having
experienced suicidal ideation within the last year, and almost 80 %
having seriously considered death by suicide at some point in their lives
(Testa et al., 2017). It is therefore critically important to identify factors
that may be protective and buffer the effects of minority stressors on
mental health. Minority stress models (Meyer, 2003) suggest that social
support and coping may moderate the effects of minority stress and
mental health outcomes. One signicant source of support that con-
tributes to positive wellbeing is involvement in a romantic relationship
(Kamp Dush and Amato, 2005; Landolt et al., 2023).
1.2. Does relationship involvement buffer minority stress?
Most people wish to have a romantic relationship at some point in
their lives (Fletcher et al., 2015; Roberts and Robins, 2000), and much
evidence – from largely cisgender-heterosexual samples – indicates that
being in a satisfying romantic relationship is a strong predictor of pos-
itive mental health and wellbeing (Braithwaite and Holt-Lunstad, 2017;
Buecker et al., 2021; Diener et al., 2000; Kamp Dush and Amato, 2005;
Purol et al., 2021; Waite and Gallagher, 2001; Whisman and Baucom,
2012). In addition to the direct effects of relationship status on in-
dicators of mental health and well-being, stress buffering models (Cohen
and Wills, 1985) conceptualize how the benets associated with rela-
tionship involvement, such as social support, may buffer the negative
mental health effects of external life stressors. Indeed, much evidence
indicates that supportive and fullling romantic relationships can buffer
the effects of a range of life stressors (Hilpert et al., 2018; Meuwly et al.,
2012; Revenson et al., 2005; Traa et al., 2014; Waite and Gallagher,
2001).
Several studies have found overall positive effects of being in a
romantic relationship among gender and sexual minority adults (e.g.,
Whitton et al., 2020, 2021), though evidence is mixed regarding
whether being partnered buffers the effects of minority stress on mental
health. For instance, in same-sex attracted youth, Baams et al. (2014)
found that relationship status (being partnered) buffered the effects of
anticipated rejection on psychological well-being but did not buffer the
effects of other minority stressors. Feinstein et al. (2016) found that
relationship status buffered the mental health effects of minority stress
among bisexual individuals but not gay or lesbian-identied individuals.
Relationship involvement buffered the effects of victimization on psy-
chological distress in a sample of sexual minority youth (Whitton et al.,
2018a) but not in a sample of young gender and sexual minority in-
dividuals assigned female at birth (Whitton et al., 2021).
What might explain this somewhat inconsistent pattern of results?
The effect of relationship status on well-being outcomes is complex and
some have argued that the benets typically ascribed to romantic
involvement are overstated (DePaulo and Morris, 2005). Associations
between relationship status and well-being vary in magnitude (Pepping
and MacDonald, 2020) and there is signicant within-group heteroge-
neity among both partnered and single individuals (e.g., Girme et al.,
2023; Pepping et al., 2018b; Pepping et al., 2024). Of particular
importance, the benets of being in a romantic relationship likely stem
from being in a satised relationship; relationship distress is a strong
predictor of poor mental health outcomes (Whisman, 2007). Consistent
with this proposition, evidence from samples of partnered gender and
sexual minority individuals suggests that relationship quality moderates
the effects of discrimination (Robles et al., 2022) and internalized stigma
(Sarno et al., 2022) on mental health, such that effects of minority
stressors are attenuated at higher levels of relationship quality.
Minority stress increases couple conict (Nguyen and Pepping,
2022) and undermines relationship functioning in gender and sexual
minority adults (Pepping et al., 2019, 2024) and it therefore seems likely
that, for some, being in a romantic relationship may not be protective.
Further, when considering the unique relationship experiences of TNB
individuals, whose partners may be a key source of minority stress (e.g.,
rejection from partners during transition, or sexual fetishization from
partners; Perez and Pepping, 2024), it seems especially likely that any
buffering role of relationship involvement would be most evident in
non-distressed relationships.
1.3. The present research
A growing body of evidence suggests that being in a romantic rela-
tionship has broad mental health benets among sexual minority in-
dividuals (e.g., Whitton et al., 2021), though whether relationship
involvement buffers the effects of minority stress is less clear, and
research specic to TNB individuals is lacking. The aims of the present
research were to: (1) examine whether relationship status (single vs.
partnered) was associated with mental health outcomes (depressive
symptoms and suicidal ideation) among TNB adults; (2) test whether
being in a romantic relationship buffered the effects of minority stress on
mental health; and (3) examine whether any buffering role of relation-
ship status is limited to those in satisfying relationships.
Our hypotheses were as follows: (1) being partnered (relative to
single) would be associated with more positive mental health (fewer
depressive symptoms and less suicidal ideation); (2) relationship status
(single vs. partnered) would moderate associations between minority
stressors (victimization, rejection, and discrimination) and mental
health, such that the effects of minority stress on the mental health
outcomes would be weaker among those who were partnered; (3)
relationship group (single vs. distressed partnered vs. satised part-
nered) would moderate associations between minority stress and mental
health outcomes, such that, relative to the single group, associations
between minority stress and mental health outcomes would be weaker
among those in satised relationships, but not distressed relationships.
Additional exploratory analyses were conducted to test whether de-
mographic factors (i.e., gender, ethnicity, sexual orientation, and part-
ner gender) moderated any buffering effects of relationship status. We
also tested general interpersonal satisfaction as a moderator to examine
whether any buffering effects were specic to romantic relationships, or
whether satisfying close relationships in general would buffer effects of
minority stress on depressive symptoms and suicidal ideation.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
635
2. Method
2.1. Participants
Participants were 1156 TNB individuals aged between 18 and 70
years (M
age
=23.69 years, SD =7.72). Just over a third, 409 (35.4 %)
resided in Australia, and 747 (64.6 %) in the USA.
1
Just over half the
sample (52.4 %) identied as non-binary and/or gender diverse, with
the remainder identifying as men (34.1 %) or women (13.5 %). More
than 80 % were assigned female at birth, and participants reported a
range of sexual orientations, including pansexual, queer, bisexual, and
gay or lesbian. More than 80 % of the sample identied as white, and
just under 10 % identied as multiracial. Regarding relationship status,
654 participants (56.6 %) were currently in a romantic relationship, and
502 participants (43.4 %) were currently single. Further demographic
details are provided in OSM Table 1. We followed procedures to detect
and prevent survey bots and/or troll responses (see Xu et al., 2022),
including examining open-ended response options, and reviewing
timestamps and response patterns.
2.2. Measures
2.2.1. Relationship status
Participants were asked “Are you currently in a romantic relation-
ship or relationships?” and responded either Yes (coded as 1) or No
(coded as 0).
2.2.2. Minority stress
We used three subscales of the Gender Minority Stress and Resilience
Measure (Testa et al., 2015) to assess Victimization (e.g., “I have been
threatened with harm because of my gender identity or expression”), Rejec-
tion (e.g., “I have been rejected or distanced from family because of my
gender identity or expression”), and discrimination (e.g., “Because of my
gender identity or expression, I have had difculty nding a bathroom to use
when I am out in public”). Response options for these subscales are (1)
Never; (2) Yes, before age 18; (3) Yes, after age 18; (4) Yes, in the past year.
Responses for each item were then coded as either 1 (Yes, at any time) or
0 (Never). Internal consistency was adequate and comparable to past
studies (
α
=0.60–0.78; Testa et al., 2015).
2.2.3. Depressive symptoms
We used the depression subscale of the Depression, Anxiety and
Stress Scale (DASS-21; Lovibond and Lovibond, 1995) as an indicator of
depressive symptoms. Participants are asked to respond to 7 statements
(e.g., “I felt down-hearted and blue”) based on the past week, and
response options range from 0 (Did not apply to me at all) to 3 (Applied to
me most of the time). The DASS-21 has been widely used in both clinical
and non-clinical samples and displays excellent validity and reliability
(Lovibond and Lovibond, 1995). Internal consistency was high (
α
=
0.92).
2.2.4. Suicidal ideation
The 4-item Suicidal Behaviors Questionnaire-Revised (SBQ-R;
Osman et al., 2001) is a widely measure of suicidal thoughts and prior
suicidal behavior. To assess recent suicidality (rather than history of
lifetime suicide attempts given our focus on the moderating role of
current relationship status), we used the mean of the relevant two items
from this scale: “How often have you thought about killing yourself in the
past year?” and “How likely is it that you will attempt suicide someday?”.
Internal consistency was high (
α
=0.75).
2.2.5. Romantic relationship distress
Those in a romantic relationship responded to an item from the
Outcome Questionnaire-45.2 (Lambert et al., 2004) to assess relation-
ship distress: “I feel unhappy in my marriage/signicant relationship”.
Participants responded on a 5-point Likert scale from 0 (Never) to 4
(Always). Those who scored 2 (Sometimes), 3 (Frequently), or 4 (Always)
were classied as distressed, and those scoring below the mid-point (i.e.,
those who scored 0 (Never) or 1 (Rarely)) were classied as not
distressed.
2.2.6. General interpersonal satisfaction
The full sample responded to an item from the Outcome
Questionnaire-45.2 (Lambert et al., 2004) to assess general interper-
sonal satisfaction: “I am satised with my relationships with others”.
Participants responded on a 5-point Likert scale from 0 (Never) to 4
(Always). Because responses to this item were available for the full
sample – not just those in a romantic relationship – there was no need to
dichotomize this variable and it was therefore used as a continuous
variable.
2.3. Procedure
Ethics approval was obtained from the La Trobe University Human
Research Ethics Committee (Ethics Approval Number: HEC18110).
Recruitment occurred in 2018 and participation was open to people
aged 18 or older who identied as transgender, gender diverse, or non-
binary and who lived either in the USA or Australia. The study was
advertised using paid social media advertisements which were targeted
to be shown to residents of the USA and Australia aged 18 and above
who had interests relevant to the target population (e.g., “genderqueer”
or “transgender”) associated with their prole and/or account use.
Participants were directed to a Participant Information Statement which
outlined the aims of the broader study – to examine the effects of mi-
nority stress and dysphoria on TNB psychological well-being, and factors
associated with coping and resilience – and provided additional study
information, such as details of support services, and contact details of
the research team should participants have questions about the research.
If individuals wished to participate after having read the Participant
Information Statement, they then provided consent by selecting the
relevant response, which then loaded the questionnaire for completion.
The questionnaire was hosted on Qualtrics and included the measures
mentioned above and several others that were not related to this study.
Completion took approximately 15–20 min.
2.4. Statistical analyses
Descriptive statistics and correlations are provided for the key study
variables in OSM Table 2. For Item 2 of the SBQ-4, which measures past
year frequency of thoughts of suicide, 403 individuals (34.9 %) indi-
cated having such thoughts very often (5 or more times), 190 (16.4 %)
had such thoughts often (3–4 times), 229 (19.8) sometimes (2 times), 158
(13.7 %) rarely (1 time), and 176 (15.2 %) never.
Regarding the main analyses, we used Model 1 of the PROCESS
Macro (Hayes, 2022) to test whether the minority stress variables
(victimization, rejection, and discrimination) were signicant predictors
of the two outcomes (depressive symptoms and suicidal ideation), and
whether relationship status (0 =single; 1 =partnered) moderated any
association. Given that partnered individuals were older than single
participants, and that age signicantly correlated with the two
1
We ran a series of independent samples t-tests with Bonferroni correc-
tions to test for differences between participants residing in the USA and
Australia. Few differences were found, though participants residing in
Australia were signicantly older (M =25.87, SD =9.99) than those living in
the USA (M =22.50, SD =5.81) (t =6.27, p <.001), and people in Australia
(M =2.54, SD =1.82) reported somewhat less rejection than those residing
in the USA (M =3.16, SD =1.79) (t = − 5.57, p <.001). To ensure any such
differences were not inuencing results, we re-ran the relevant analyses
controlling for country of residence and this did not change the pattern of
results.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
636
outcomes, we controlled for age to clarify whether relationship status
played a moderating role, separate from any effects of age.
To examine the inuence of both relationship status and the quality
of the romantic relationship, we again used Model 1 of the PROCESS
Macro (Hayes, 2022). Specically, we tested whether the minority stress
variables (victimization, rejection, and discrimination) were signicant
predictors of depressive symptoms and suicidal ideation. Consistent
with prior research on relationship status (e.g., Whitton et al., 2020), we
used a multicategorical moderator (1 =single; 2 =satised couple; 3 =
distressed couple), with the single group as the reference group, to test
whether the relationship buffer applied only to more satisfying re-
lationships. This approach was required as data for romantic relation-
ship distress was available only for partnered individuals; single
participants could not report on relationship distress with a romantic
partner, and thus it could not be entered separately as an additional
predictor, or used to create an interaction term.
3. Results
Descriptive statistics, correlations, and independent sample t-tests
with Bonferroni adjustments are displayed in OSM Table 2. Partnered
participants were signicantly older, and reported more satisfaction
with their interpersonal relationships, than their single counterparts, but
there were otherwise no mean differences. The minority stressors
correlated in expected directions with depressive symptoms and suici-
dality in the single sample, whereas discrimination was not signicantly
associated with depressive symptoms among partnered individuals.
Victimization and rejection were associated with depressive symptoms
and suicidal ideation in both samples, but the size of these correlations
was small in the partnered sample. Age was negatively associated with
depressive symptoms and suicidal ideation in both samples.
3.1. Moderating role of relationship status
We examined whether victimization, rejection, and discrimination
were signicant predictors of depressive symptoms and suicidal idea-
tion, and whether relationship status (0 =single; 1 =partnered)
moderated any association using Model 1 of the PROCESS Macro
(Hayes, 2022).
As displayed in Table 1, victimization, rejection, and discrimination
each predicted greater depressive symptoms and suicidal ideation. Being
partnered was not associated with depressive symptoms or suicidal
Table 1
Victimization, Rejection, and Discrimination Predicting Depressive Symptoms and Suicidal Ideation, Moderated by Relationship Status (Upper Half of Table) and
Relationship Status and Quality (Lower Half of Table).
Predictor Variables Outcome Variables
Depressive Symptoms Suicidal Ideation
Victimization 0.81 [0.613, 1.003] 0.20 [0.160, 0.249]
Relationship Status −0.51 [−1.194, 0.177] −0.12 [−0.274, 0.037]
Victim ×Rel. Status ¡0.73 [¡1.131, ¡0.338] ¡0.11 [¡0.200, ¡0.020]
Age ¡0.18 [¡0.233, ¡0.145] ¡0.03 [¡0.043, ¡0.023]
Rejection 0.62 [0.438, 0.810] 0.20 [0.156, 0.240]
Relationship Status −0.25 [−0.937, 0.437] −0.06 [−0.210, 0.099]
Reject ×Rel. Status ¡0.85 [¡1.234, ¡0.482] ¡0.13 [¡0.211, ¡0.042]
Age ¡0.17 [¡0.218, ¡0.129] ¡0.03 [¡0.038, ¡0.018]
Discrimination 0.45 [0.212, 0.683] 0.19 [0.137, 0.242]
Relationship Status −0.37 [−1.07, 0.335] −0.10 [−0.254, 0.060]
Discrim ×Rel. Status ¡0.57 [¡1.043, ¡0.096] −0.10 [−0.207, 0.006]
Age ¡0.18 [¡0.226, ¡0.136] ¡0.03 [¡0.041, ¡0.020]
Predictor Variables Outcome Variables
Depressive Symptoms Suicidal Ideation
Victimization 1.22 [0.920, 1.526] 0.27 [0.198, 0.336]
RS1 (Satised vs Single) ¡1.25 [¡1.974, ¡0.541] ¡0.25 [¡0.416, ¡0.089]
RS2 (Distressed vs Single) 2.01 [0.963, 3.062] 0.33 [0.087, 0.566]
Victim ×RS1 ¡0.62 [¡1.037, ¡0.208] ¡0.10 [¡0.197, ¡0.008]
Victim ×RS2 ¡1.18 [¡1.767, ¡0.586] ¡0.15 [¡0.286, ¡0.017]
Age ¡0.19 [¡0.231, ¡0.144] ¡0.03 [¡0.042, ¡0.023]
Rejection 1.11 [0.826, 1.392] 0.27 [0.205, 0.333]
RS1 (Satised vs Single) ¡0.99 [¡1.712, ¡0.273] ¡0.19 [¡0.352, ¡0.027]
RS2 (Distressed vs Single) 2.22 [1.164, 3.266] 0.39 [0.150, 0.626]
Reject ×RS1 ¡0.82 [¡1.217, ¡0.424] ¡0.12 [¡0.213, ¡0.034]
Reject ×RS2 ¡1.004 [¡1.553, ¡0.455] ¡0.14 [¡0.264, ¡0.016]
Age ¡0.17 [¡0.218, ¡0.131] ¡0.03 [¡0.038, ¡0.018]
Discrimination 0.77 [0.423, 1.117] 0.25 [0.168, 0.325]
RS1 (Satised vs Single) ¡1.13 [¡1.862, ¡0.394] ¡0.24 [¡0.404, ¡0.073]
RS2 (Distressed vs Single) 2.13 [1.057, 3.198] 0.37 [0.128, 0.611]
Discrim ×RS1 −0.48 [−0.985, 0.017] −0.09 [−0.205, 0.021]
Discrim ×RS2 −0.67 [−1.382, 0.045] −0.09 [−0.255, 0.067]
Age ¡0.18 [¡0.226, ¡0.137] ¡0.03 [¡0.041, ¡0.021]
Note: Upper half of table displays results for moderating effect of relationship status. Bottom half of table displays moderating effect of relationship status and quality.
Victim =Victimization; Reject =Rejection; Discrim =Discrimination; Rel. Status =Relationship Status.
Signicant effects bolded for ease of interpretation.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
637
ideation. We now turn to the interactions between relationship status
and minority stress.
3.1.1. Depressive symptoms
The interactions between relationship status (single vs. partnered)
and each of the minority stressors (victimization, rejection, and
discrimination) were signicant predictors of depressive symptoms (see
Table 1). When victimization and discrimination were low (−1 SD below
the mean) or at the mean, single and partnered individuals did not differ
in depressive symptoms (See Table 2 and Fig. 1). At high levels of
victimization and discrimination (+1 SD above the mean), partnered
individuals reported less depressive symptomatology than their single
counterparts (see Table 2 and Fig. 1). Regarding rejection, singles were
somewhat lower in depressive symptoms than partnered individuals at
low levels of rejection, and the groups did not differ when rejection was
at the mean. However, at high levels of rejection, partnered individuals
reported fewer depressive symptoms than their single counterparts (see
Table 2 and Fig. 1).
3.1.2. Suicidal ideation
The interaction between relationship status (single vs. partnered)
and victimization was a signicant predictor of suicidal ideation (see
Table 1). When victimization was high (+1 SD above the mean), part-
nered individuals reported less suicidal ideation than did single in-
dividuals (See Table 2 and Fig. 2). Similarly, the interaction between
relationship status and rejection was a signicant predictor of suicidal
ideation (Table 1). The groups did not differ when rejection was low (−1
SD below the mean) or at the mean. At high level of rejection, partnered
individuals reported less suicidal ideation than their single counterparts
(See Table 2 and Fig. 2). Finally, the interaction between relationship
status and discrimination was not a signicant predictor of suicidal
ideation (Table 1).
3.1.3. Summary
Relationship status (being partnered) appears to buffer the effects of
minority stressors on depressive symptoms and suicidal ideation. With
one exception (relationship status did not buffer the effects of discrim-
ination on suicidal ideation), being partnered was protective against the
effects of heightened minority stress in TNB adults. We next examined
whether the buffering effects of romantic relationships applied to all
people in relationships, or only those in satisfying relationships.
Table 2
Effects of Minority Stressors and Relationship Status (Upper Half of Table) and Relationship Status and Quality (Lower Half of Table) on Depressive Symptoms and
Suicidal Ideation.
Levels of the IV and Moderator Outcome Variables
Depressive Symptoms Suicidal Ideation
Single Vs. Partnered
Victimization (−1 SD) 0.76 [−0.195, 1.724] 0.07 [−0.145, 0.290]
Victimization (M)−0.51 [−1.194, 0.177] −0.12 [−0.274, 0.037]
Victimization (+1 SD)¡1.78 [¡2.764, ¡0.799] ¡0.31 [¡0.533, ¡0.087]
Single Vs. Partnered
Rejection (−1 SD)1.31 [0.339, 2.286] 0.17 [−0.045, 0.393]
Rejection (M)−0.25 [−0.937, 0.437] −0.06 [−0.210, 0.099]
Rejection (+1 SD)¡1.81 [¡2.781, ¡0.846] ¡0.29 [¡0.503, ¡0.068]
Single Vs. Partnered
Discrimination (−1 SD) 0.47 [−0.513, 1.447] 0.05 [−0.171, 0.269]
Discrimination (M)−0.37 [−1.066, 0.335] −0.10 [−0.254, 0.060]
Discrimination (+1 SD)¡1.20 [¡2.187, ¡0.208] ¡0.24 [¡0.466, ¡0.021]
Levels of the IV and Moderator Outcome Variables
Depressive Symptoms Suicidal Ideation
Single Vs. Partnered (Satised)
Victimization (−1 SD)−0.18 [−1.183, 0.826] −0.07 [−0.304, 0.154]
Victimization (M)¡1.26 [¡1.974, ¡0.541] ¡0.252 [¡0.416, ¡0.089]
Victimization (+1 SD)¡2.34 [¡3.360, ¡1.313] ¡0.43 [¡0.663, ¡0.195]
Single Vs. Partnered (Distressed)
Victimization (−1 SD)4.05 [2.543, 5.561] 0.59 [0.245, 0.934]
Victimization (M)2.01 [0.963, 3.062] 0.33 [0.087, 0.566]
Victimization (+1 SD)−0.03 [−1.45, 1.39] 0.06 [−0.261, 0.389]
Single Vs. Partnered (Satised)
Rejection (−1 SD) 0.50 [−0.516, 1.524] 0.04 [−0.194, 0.267]
Rejection (M)¡0.99 [¡1.712, ¡0.273] ¡0.19 [¡0.352, ¡0.027]
Rejection (+1 SD)¡2.49 [¡3.507, ¡1.469] ¡0.41 [¡0.645, ¡0.184]
Single Vs. Partnered (Distressed)
Rejection (−1 SD)4.04 [2.584, 5.504] 0.64 [0.313, 0.973]
Rejection (M)2.22 [1.164, 3.266] 0.39 [0.150, 0.626]
Rejection (+1 SD) 0.39 [−1.057, 1.829] 0.13 [−0.193, 0.459]
Note: Upper half of table displays results for moderating effect of relationship status (single vs. partnered). Bottom half of table displays moderating effect of rela-
tionship status and quality (single vs. satised partnered vs. distressed partnered).
Signicant effects bolded for ease of interpretation.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
638
3.2. Moderating role of relationship status and distress
We again used Model 1 of the PROCESS Macro (Hayes, 2022) to test
whether the minority stressors predicted depressive symptoms and
suicidal ideation, and whether relationship status/distress moderated
these effects. As described earlier, we used a multicategorical moderator
(1 =single; 2 =satised couple; 3 =distressed couple), with the single
group as the reference group, to test whether the relationship buffer
applied only to those in more satisfying relationships.
As displayed in Table 1, victimization, rejection, and discrimination
were each associated with more depressive symptoms and greater sui-
cidal ideation. Relationship status also predicted both outcomes. Spe-
cically, those in satisfying relationships showed fewer depressive
symptoms and less suicidal ideation than their single counterparts,
whereas those in distressed relationships showed greater depressive
symptoms and suicidal ideation than single people.
3.2.1. Depressive symptoms
The interactions between RS1 (Satised Couple vs. Single) and both
victimization and rejection, and between RS2 (Distressed Couple vs.
Fig. 1. Effects of victimization, rejection, and discrimination on depressive
symptoms, moderated by relationship status.
Fig. 2. Effects of victimization and rejection on suicidal ideation, moderated by
relationship status.
Fig. 3. Effects of victimization and rejection on depressive symptoms, moder-
ated by relationship status and quality.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
639
Single) and both victimization and rejection, were signicant predictors
of depressive symptoms (see Table 1). Relative to single individuals,
those in satisfying romantic relationships reported fewer depressive
symptoms at average or high (+1 SD above the mean) levels of victim-
ization and rejection (see Table 2 and Fig. 3). However, no such buff-
ering effect was found for those in distressed romantic relationships.
Specically, those in distressed relationships were higher in depressive
symptoms at low or mean levels of victimization and rejection and did
not differ from their single counterparts at high victimization and
rejection (+1 SD above the mean; see Table 2 and Fig. 3). There was no
signicant interaction between discrimination and relationship status.
3.2.2. Suicidal ideation
The interactions between RS1 (Satised Couple vs. Single) and both
victimization and rejection, and between RS2 (Distressed Couple vs.
Single) and both victimization and rejection, were signicant predictors
of suicidal ideation (See Table 1). Relative to single individuals, those in
satisfying romantic relationships reported less suicidal ideation at
average or high (+1 SD above the mean) levels of victimization and
rejection (see Table 2 and Fig. 4). Again, no such buffering effect was
found for those in distressed relationships. Those in distressed re-
lationships displayed greater suicidal ideation at low or mean levels of
victimization and rejection and did not differ from their single coun-
terparts at high victimization and rejection (+1 SD above the mean; see
Table 2 and Fig. 4). Again, there was no signicant interaction between
discrimination and relationship status.
3.3. Exploratory analyses
Demographic characteristics (gender, sexual orientation, ethnicity,
relationship duration, and partner gender) did not inuence the buff-
ering effects of relationship status (see OSM Results 1). Further, general
interpersonal satisfaction (OSM Results 2) did not buffer the effects of
minority stress when tested in both the full sample (OSM Table 3) and
single sample only (OSM Table 4).
4. Discussion
This study examined whether romantic relationship involvement
buffered the effects of minority stress on depressive symptoms and sui-
cidal ideation in TNB adults. Here we provide new evidence that
romantic involvement plays a stress-buffering role, but that the quality
of the relationship matters. Specically, the effects of victimization and
rejection on depressive symptoms and suicidal ideation were attenuated
among partnered individuals, but these buffering effects applied only to
those in more satisfying relationships; at high levels of victimization and
rejection, those in distressed relationships did not differ from their single
counterparts in depressive symptoms or suicidal ideation. In contrast to
interpersonal minority stressors (i.e., rejection and victimization), the
buffering effects of relationship involvement were less consistent for
more systemic forms of discrimination.
There were no main effects of relationship involvement (single vs.
partnered) on depressive symptoms or suicidal ideation, suggesting that
romantic relationships play a stress buffering role – given the signicant
moderation effects – rather than a direct effect. However, there were
signicant main effects of relationship status when considering rela-
tionship quality; relative to single individuals, those in satisfying
romantic relationships displayed fewer depressive symptoms and less
suicidal ideation, whereas those in distressed relationships fared worse
than their single counterparts. Demographic characteristics did not
moderate any effects of romantic involvement. Furthermore, general
interpersonal satisfaction did not act as a minority stress buffer, sug-
gesting there may be unique stress-buffering effects of being in a satis-
fying romantic relationship. Taken together, results clearly suggest that
relationship involvement is protective against the mental health effects
of TNB minority stress, but the stress-buffering function of relationship
involvement applies mainly to those in satisfying relationships. We
discuss the implications of these ndings in the sections that follow.
4.1. Stress buffering role of romantic relationships
Being partnered buffered the effects of victimization and rejection on
depressive symptoms and suicidal ideation. Results are consistent with
theories that conceptualize romantic relationships as a stress buffer
(Cohen and Wills, 1985; Landolt et al., 2023), and with evidence from
cisgender samples showing that supportive and fullling romantic re-
lationships can buffer the effects of a range of stressors (e.g., Hilpert
et al., 2018; Meuwly et al., 2012). As mentioned earlier, studies exam-
ining the buffering role of romantic involvement have produced mixed
ndings in samples of sexual minority individuals (e.g., Baams et al.,
2014; Feinstein et al., 2016; Whitton et al., 2018a, 2021), with results
varying by demographic characteristics (e.g., sexual orientation) and the
type of minority stress examined. The present study is the rst to address
these questions specically in a TNB sample, and results clearly suggest
that romantic involvement can protect against the mental health effects
of minority stress. The stress buffering role of romantic involvement did
not differ by demographic characteristics such as gender, sexual orien-
tation, ethnicity, relationship duration, or partner gender status (cis-
gender vs. TNB).
One of the most important ndings of our research is that the pro-
tective effects of romantic involvement apply only to those who are
satised in their relationship; individuals in distressed relationships did
not differ from their single counterparts at high levels of minority stress
and fared worse overall in depressive symptoms and suicidal ideation.
This may be why previous studies testing the buffering effects of
romantic involvement (single vs. partnered) in sexual minority pop-
ulations, without accounting for the quality of these relationships, have
found mixed results; this does need to be explicitly tested, however.
Fig. 4. Effects of victimization and rejection on suicidal ideation, moderated by
relationship status and quality.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
640
When considering the unique relationship experiences of TNB in-
dividuals, whose partners can be a key source of minority stress (e.g.,
through rejection, fetishization, or victimization; Perez and Pepping,
2024), the nding that only satisfying romantic relationships buffer
against minority stress is unsurprising. These ndings speak to the
complexities of studying the effects of relationship status on mental
health and well-being (Girme et al., 2023; Park et al., 2024; Pepping
et al., b; Pepping et al., 2024) and converge with evidence that rela-
tionship distress is a strong predictor of poorer mental health outcomes
(Whisman, 2007). Results are also consistent with evidence that single
people tend to fare better than those in unhappy relationships (Holt-
Lunstad et al., 2010).
In the present study, relationship involvement and quality buffered
the mental health effects of victimization (e.g., verbal harassment,
threats, physical violence) and rejection (e.g., from friends or family),
both of which are interpersonal in nature. This is somewhat consistent
with prior research with sexual minority young people whereby rela-
tionship involvement only buffered the effects of expected rejection on
well-being outcomes (Baams et al., 2014). However, with one exception,
relationship involvement and quality did not buffer the effects of more
systemic forms of discrimination, such as difculties with legal docu-
mentation, or challenges nding a bathroom to use when in public. This
was unexpected given evidence that romantic relationships have pro-
tective qualities for coping with a range of stressors in the general
population (Landolt et al., 2023; Merz et al., 2014; Traa et al., 2014;
Weitkamp et al., 2021). It is unclear why relationship involvement and
quality largely did not buffer mental health effects of more systemic
discrimination; however, at least in the current sample of TNB in-
dividuals, the stress buffering effects of relationship involvement
occurred largely for minority stressors that are interpersonal in nature.
Of particular importance is the nding that the stress-buffering ef-
fects on depressive symptoms and suicidal ideation were specic to
romantic relationships; although general interpersonal satisfaction was
associated with fewer depressive symptoms and less suicidal ideation in
both single and partnered individuals, it did not buffer the mental health
effects of minority stress. This parallels evidence that general social
support tends not to be a reliable buffer of minority stress among TNB
individuals (Grocott et al., 2023; Rimmer et al., 2023) and suggests there
may be unique protective qualities of (satisfying) romantic
relationships.
4.2. Implications, limitations, and future directions
The results of the present research suggest that romantic involve-
ment may buffer the effects of TNB minority stress on depressive
symptoms and suicidality, but the stress-buffering effects are observed
only for those in more satisfying relationships. These ndings support
recent calls to account for within-group heterogeneity when investi-
gating well-being in single and partnered individuals (e.g., DePaulo and
Morris, 2005; Girme et al., 2023; Park et al., 2024; Pepping et al., b)
given the limitations of simply comparing single and partnered in-
dividuals. Second, our results suggest that being in a satisfying romantic
relationship is a positive personal resource that buffers the mental
health effects of minority stress, consistent with early theorizing (Meyer,
2003) and with evidence highlighting the importance of interpersonal
factors in depression and suicidality (Christensen et al., 2013; Struck
et al., 2020). Here we found that these effects were specic to romantic
relationships; general interpersonal satisfaction did not buffer the effects
of minority stress. Given there has been mixed evidence as to the role of
social support as a TNB minority stress buffer (Grocott et al., 2023;
Helsen et al., 2022; Rimmer et al., 2023), our results suggest that the
type and quality of the relationship matters and further research is
needed to examine the conditions under which relationship processes
buffer minority stress effects.
Reducing societal stigma remains an essential public health goal to
address the mental health disparities between TNB and their cisgender
peers. However, while societal stigma remains, identifying effective
ways to support TNB individuals in coping with the effects of minority
stress remains important. The results of the present study suggest that
interventions designed to strengthen romantic relationships, such as
couple therapy or relationship education (Halford and Bodenmann,
2013; Halford and Pepping, 2019), could help to buffer the effects of
minority stress on depressive symptoms and suicidality. As with rela-
tionship interventions for sexual minority couples (e.g., Pepping et al.,
2017; Pepping and Halford, 2014; Scott et al., 2019; Whitton et al.,
2018b; Whitton and Buzzella, 2012), modications and tailoring would
be needed for the intervention to be appropriate, inclusive, and relevant
to the needs of TNB individuals. Relationship interventions have shown
promise for enhancing relationships and mental health among sexual
minority individuals (e.g., Pepping et al., 2020; Whitton et al., 2016,
2017), though further work is needed to trial interventions for TNB in-
dividuals in relationships. Efforts are also needed to ensure that such
interventions are accessible given the signicant barriers faced by TNB
individuals when seeking help (Cronin et al., 2023; Lim et al., 2021), and
that practitioners are adequately trained and competent to work effec-
tively with TNB individuals and couples (e.g., Pachankis et al., 2022;
Pepping et al., 2018a).
To our knowledge, the present study was the rst to investigate the
stress-buffering role of romantic involvement exclusively among TNB
adults, and the rst to consider the role of both relationship involvement
and quality. Further, we tested our hypotheses in a large and reasonably
diverse sample of TNB individuals. Nonetheless, there are some caveats
and limitations to consider. First, although the results are in line with
theoretically driven hypotheses and empirical research, the cross-
sectional nature of the present study precludes denitive conclusions
regarding causation. Nonetheless, the ndings clearly suggest that the
mental health effects of minority stress are lower for those TNB in-
dividuals in satisfying romantic relationships. Further research should
examine TNB relationship involvement and quality as a minority stress-
buffer over time. In addition, regarding suicidal ideation, here we
focused on current suicidal ideation given our aims and hypotheses
related to the moderating role of current relationship status. However,
future longitudinal research should examine the role of relationship
involvement on suicidal behaviors/attempts. Although there was di-
versity in sexual orientation and gender identity, ethnicity was some-
what less varied, with 83.5 % of participants identifying as white.
Although we were able to examine ethnicity as a moderator using a
binary variable (white vs. person of colour), greater diversity in the
sample would allow for more ne-grained analysis of various back-
grounds. Further research is needed to address such questions. Explor-
atory analyses found that general interpersonal satisfaction did not
buffer effects of minority stress; research is needed to identify factors
that buffer the mental health effects of minority stress in single TNB
adults.
5. Conclusions
The present research examined whether being partnered was pro-
tective against the mental health effects of TNB minority stress. We
found clear evidence that romantic involvement buffered associations
between two key aspects of TNB minority stress – rejection and
victimization – and mental health outcomes. Once relationship quality
was considered, these stress-buffering effects were observed only for
those in satisfying romantic relationships; being in a distressed rela-
tionship did not protect against the mental health impacts of minority
stress. Of particular importance, the stress-buffering effects were specic
to romantic relationships; general interpersonal satisfaction did not
buffer the effects of minority stress for single or partnered individuals.
These results provide us with greater insight into factors that might be
protective against TNB minority stress and suggest that interventions
targeting relationship factors may be a fruitful avenue to investigate.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
641
Funding source
No funding was received for this specic research.
CRediT authorship contribution statement
Christopher A. Pepping: Writing – original draft, Supervision,
Methodology, Formal analysis, Conceptualization. Natasha Belmont:
Writing – review & editing, Data curation, Conceptualization. Timothy
J. Cronin: Writing – review & editing, Supervision, Conceptualization.
Declaration of competing interest
All authors declare that they have no conicts of interest.
Data availability
The data pertaining to this manuscript are available upon reasonable
request to the corresponding author.
Acknowledgements
None
Appendix A. Supplementary material
Supplementary material to this article can be found online at htt
ps://doi.org/10.1016/j.jad.2024.06.062.
References
Adams, N.J., Vincent, B., 2019. Suicidal thoughts and behaviors among transgender
adults in relation to education, ethnicity, and income: a systematic review.
Transgender Health 4 (1), 226–246.
Baams, L., Bos, H.M.W., Jonas, K.J., 2014. How a romantic relationship can protect
same-sex attracted youth and young adults from the impact of expected rejection.
J. Adolesc. 37 (8), 1293–1302. https://doi.org/10.1016/j.adolescence.2014.09.006
(Scopus).
Belmont, N., Cronin, T. J., & Pepping, C. A. (2023). Afrmation-support, parental
conict, and mental health outcomes of transgender and gender diverse youth. Int. J.
Transgender Health, 0(0), 1–13. doi:https://doi.org/10.1080/26895269.2023.2252
418.
Bockting, W.O., Miner, M.H., Swinburne Romine, R.E., Hamilton, A., Coleman, E., 2013.
Stigma, mental health, and resilience in an online sample of the US transgender
population. Am. J. Public Health 103 (5), 943–951. https://doi.org/10.2105/
AJPH.2013.301241.
Bouman, W.P., Claes, L., Brewin, N., Crawford, J.R., Millet, N., Fernandez-Aranda, F.,
Arcelus, J., 2017. Transgender and anxiety: a comparative study between
transgender people and the general population. International Journal of
Transgenderism 18 (1), 16–26. https://doi.org/10.1080/15532739.2016.1258352.
Boza, C., Nicholson Perry, K., 2014. Gender-related victimization, perceived social
support, and predictors of depression among transgender Australians. International
Journal of Transgenderism 15 (1), 35–52. https://doi.org/10.1080/
15532739.2014.890558.
Braithwaite, S., Holt-Lunstad, J., 2017. Romantic relationships and mental health. Curr.
Opin. Psychol. 13, 120–125. https://doi.org/10.1016/j.copsyc.2016.04.001.
Budge, S.L., Adelson, J.L., Howard, K.A.S., 2013. Anxiety and depression in transgender
individuals: the roles of transition status, loss, social support, and coping. J. Consult.
Clin. Psychol. 81 (3), 545–557. https://doi.org/10.1037/a0031774.
Buecker, S., Denissen, J.J.A., Luhmann, M., 2021. A propensity-score matched study of
changes in loneliness surrounding major life events. J. Pers. Soc. Psychol. 121 (3),
669–690. https://doi.org/10.1037/pspp0000373.
Chodzen, G., Hidalgo, M.A., Chen, D., Garofalo, R., 2019. Minority stress factors
associated with depression and anxiety among transgender and gender-
nonconforming youth. J. Adolesc. Health 64 (4), 467–471. https://doi.org/10.1016/
j.jadohealth.2018.07.006.
Christensen, H., Batterham, P.J., Soubelet, A., Mackinnon, A.J., 2013. A test of the
Interpersonal Theory of Suicide in a large community-based cohort. J. Affect. Disord.
144 (3), 225–234. https://doi.org/10.1016/j.jad.2012.07.002.
Cohen, S., Wills, T.A., 1985. Stress, social support, and the buffering hypothesis. Psychol.
Bull. 98 (2), 310–357. https://doi.org/10.1037/0033-2909.98.2.310.
Cronin, T.J., Pepping, C.A., Lyons, A., 2023. Mental health service use and barriers to
accessing services in a cohort of transgender, gender diverse, and non-binary adults
in Australia. Sex. Res. Soc. Policy. https://doi.org/10.1007/s13178-023-00866-4.
DePaulo, B.M., Morris, W.L., 2005. TARGET ARTICLE: singles in society and in science.
Psychol. Inq. 16 (2–3), 57–83. https://doi.org/10.1080/1047840X.2005.9682918.
Diener, E., Gohm, C.L., Suh, E., Oishi, S., 2000. Similarity of the relations between
marital status and subjective well-being across cultures. J. Cross-Cult. Psychol. 31
(4), 419–436. https://doi.org/10.1177/0022022100031004001.
Feinstein, B.A., Latack, J.A., Bhatia, V., Davila, J., Eaton, N.R., 2016. Romantic
relationship involvement as a minority stress buffer in gay/lesbian versus bisexual
individuals. J. Gay Lesbian Ment. Health 20 (3), 237–257. https://doi.org/10.1080/
19359705.2016.1147401.
Fletcher, G.J., Simpson, J.A., Campbell, L., Overall, N.C., 2015. Pair-bonding, romantic
love, and evolution: the curious case of Homo sapiens. Perspect. Psychol. Sci. 10 (1),
20–36.
Girme, Y.U., Park, Y., MacDonald, G., 2023. Coping or thriving? Reviewing
intrapersonal, interpersonal, and societal factors associated with well-being in
singlehood from a within-group perspective. Perspect. Psychol. Sci. 18 (5),
1097–1120.
Grocott, L.R., Schlechter, T.E., Wilder, S.M.J., O’Hair, C.M., Gidycz, C.A., Shorey, R.C.,
2023. Social support as a buffer of the association between sexual assault and trauma
symptoms among transgender and gender diverse individuals. J. Interpers. Violence
38 (1–2), 1738–1761. https://doi.org/10.1177/08862605221092069.
Halford, W.K., Bodenmann, G., 2013. Effects of relationship education on maintenance of
couple relationship satisfaction. Clin. Psychol. Rev. 33 (4), 512–525. https://doi.
org/10.1016/j.cpr.2013.02.001.
Halford, W.K., Pepping, C.A., 2019. What every therapist needs to know about couple
therapy. Behav. Chang. 36 (3), 121–142. https://doi.org/10.1017/bec.2019.12.
Hanna, B., Desai, R., Parekh, T., Guirguis, E., Kumar, G., Sachdeva, R., 2019. Psychiatric
disorders in the U.S. transgender population. Ann. Epidemiol. 39, 1–7.e1. https://
doi.org/10.1016/j.annepidem.2019.09.009.
Hatzenbuehler, M.L., 2009. How does sexual minority stigma “get under the skin”?
A psychological mediation framework. Psychological Bulletin 135 (5), 707–730.
https://doi.org/10.1037/a0016441.
Hayes, A.F., 2022. Introduction to Mediation, Moderation, and Conditional Process
Analysis: A Regression-based Approach, Third edition. The Guilford Press.
Helsen, V., Enzlin, P., Gijs, L., 2022. Mental health in transgender adults: the role of
proximal minority stress, community connectedness, and gender nonconformity.
Psychol. Sex. Orientat. Gend. Divers. 9 (4), 466–477. https://doi.org/10.1037/
sgd0000530.
Hill, A., Lyons, A., Jones, J., McGowan, I., Carman, M., Parsons, M., Power, J.,
Bourne, A., 2021. Writing Themselves In 4: the health and wellbeing of LGBTQA+
young people in Australia. National report. https://opal.latrobe.edu.au/articles/re
port/Writing_Themselves_In_4_The_health_and_wellbeing_of_LGBTQA_young_people_
in_Australia_National_report_/13647860.
Hilpert, P., Xu, F., Milek, A., Atkins, D., Bodenmann, G., Bradbury, T., 2018. Couples
coping with stress: between-person differences and within-person processes. J. Fam.
Psychol. 32 https://doi.org/10.1037/fam0000380.
Holt-Lunstad, J., Smith, T.B., Layton, J.B., 2010. Social relationships and mortality risk: a
meta-analytic review. PLoS Med. 7 (7), e1000316 https://doi.org/10.1371/journal.
pmed.1000316.
Kamp Dush, C., Amato, P., 2005. Consequences of relationship status and quality for
subjective well-being. J. Soc. Pers. Relat. 22, 607–627. https://doi.org/10.1177/
0265407505056438.
Kidd, J.D., Tettamanti, N.A., Kaczmarkiewicz, R., Corbeil, T.E., Dworkin, J.D.,
Jackman, K.B., Hughes, T.L., Bockting, W.O., Meyer, I.H., 2023. Prevalence of
substance use and mental health problems among transgender and cisgender U.S.
adults: results from a national probability sample. Psychiatry Res. 326, 115339
https://doi.org/10.1016/j.psychres.2023.115339.
Lambert, M.J., Morton, J.J., Hateld, D., Harmon, C., Hamilton, S., 2004. Administration
and Scoring Manual for the OQ-45.2 (Outcome Questionnaire). American
Professional Credentialing Services.
Landolt, S.A., Weitkamp, K., Roth, M., Sisson, N.M., Bodenmann, G., 2023. Dyadic
coping and mental health in couples: a systematic review. Clin. Psychol. Rev. 106,
102344 https://doi.org/10.1016/j.cpr.2023.102344.
Leonard, W., Lyons, A., Bariola, E., 2015. A Closer Look at Private Lives, p. 2.
Lim, G., Waling, A., Lyons, A., Pepping, C.A., Brooks, A., Bourne, A., 2021. Trans and
gender-diverse peoples’ experiences of crisis helpline services. Health Soc. Care
Community 29 (3), 672–684. https://doi.org/10.1111/hsc.13333.
Lovibond, P.F., Lovibond, S.H., 1995. The structure of negative emotional states:
comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression
and Anxiety Inventories. Behav. Res. Ther. 33 (3), 335–343. https://doi.org/
10.1016/0005-7967(94)00075-U.
Matsuno, E., Budge, S.L., 2017. Non-binary/genderqueer identities: a critical review of
the literature. Curr. Sex. Health Rep. 9 (3), 116–120. https://doi.org/10.1007/
s11930-017-0111-8.
Merz, C.A., Meuwly, N., Randall, A.K., Bodenmann, G., 2014. Engaging in dyadic coping:
buffering the impact of everyday stress on prospective relationship satisfaction.
Family Science 5 (1), 30–37. https://doi.org/10.1080/19424620.2014.927385.
Meuwly, N., Bodenmann, G., Germann, J., Bradbury, T., Ditzen, B., Heinrichs, M., 2012.
Dyadic coping, insecure attachment, and cortisol stress recovery following
experimentally induced stress. J. Fam. Psychol. 43, 26. https://doi.org/10.1037/
a0030356.
Meyer, I.H., 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual
populations: conceptual issues and research evidence. Psychol. Bull. 129 (5), 674.
https://doi.org/10.1037/0033-2909.129.5.674.
Meyer, I.H., Schwartz, S., Frost, D.M., 2008. Social patterning of stress and coping: does
disadvantaged social statuses confer more stress and fewer coping resources? Soc.
Sci. Med. 67 (3), 368–379. https://doi.org/10.1016/j.socscimed.2008.03.012.
Nguyen, J., Pepping, C.A., 2022. Prospective effects of internalized stigma on same-sex
relationship satisfaction: the mediating role of depressive symptoms and couple
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
642
conict. J. Consult. Clin. Psychol. 90 (2), 184–194. https://doi.org/10.1037/
ccp0000713.
Norris, A.L., Orchowski, L.M., 2020. Peer victimization of sexual minority and
transgender youth: a cross-sectional study of high school students. Psychol. Violence
10 (2), 201–211. https://doi.org/10.1037/vio0000260.
Osman, A., Bagge, C.L., Gutierrez, P.M., Konick, L.C., Kopper, B.A., Barrios, F.X., 2001.
The Suicidal Behaviors Questionnaire-Revised (SBQ-R): validation with clinical and
nonclinical samples. Assessment 8 (4), 443–454. https://doi.org/10.1177/
107319110100800409.
Pachankis, J.E., Soulliard, Z.A., Seager Van Dyk, I., Layland, E.K., Clark, K.A., Levine, D.
S., Jackson, S.D., 2022. Training in LGBTQ-afrmative cognitive behavioral therapy:
a randomized controlled trial across LGBTQ community centers. J. Consult. Clin.
Psychol. 90 (7), 582–599. https://doi.org/10.1037/ccp0000745.
Park, Y., Girme, Y.U., MacDonald, G., 2024. Three methodological approaches to
studying singlehood. Soc. Personal. Psychol. Compass 18 (1), e12884. https://doi.
org/10.1111/spc3.12884.
Pellicane, M.J., Ciesla, J.A., 2022. Associations between minority stress, depression, and
suicidal ideation and attempts in transgender and gender diverse (TGD) individuals:
systematic review and meta-analysis. Clin. Psychol. Rev. 91, 102113 https://doi.
org/10.1016/j.cpr.2021.102113.
Pepping, C.A., Halford, W.K., 2014. Relationship education and therapy for same-sex
couples. Aust. N. Z. J. Fam. Ther. 35 (4), 431–444. https://doi.org/10.1002/
anzf.1075.
Pepping, C.A., MacDonald, G., 2020. The inuence of attachments in close relationships
on mental health. In: Making an Impact on Mental Health. Routledge, pp. 43–70.
Pepping, C.A., Lyons, A., Halford, W.K., Cronin, T.J., Pachankis, J.E., 2017. Couple
interventions for same-sex couples: a consumer survey. Couple and Family
Psychology: Research and Practice 6 (4), 258–273. https://doi.org/10.1037/
cfp0000092.
Pepping, C.A., Lyons, A., Morris, E.M.J., 2018a. Afrmative LGBT psychotherapy:
outcomes of a therapist training protocol. Psychotherapy 55 (1), 52–62. https://doi.
org/10.1037/pst0000149.
Pepping, C.A., MacDonald, G., Davis, P.J., 2018b. Toward a psychology of singlehood: an
attachment-theory perspective on long-term singlehood. Curr. Dir. Psychol. Sci. 27
(5), 324–331. https://doi.org/10.1177/0963721417752106.
Pepping, C.A., Cronin, T.J., Halford, W.K., Lyons, A., 2019. Minority stress and same-sex
relationship satisfaction: the role of concealment motivation. Fam. Process 58 (2),
496–508. https://doi.org/10.1111/famp.12365.
Pepping, C.A., Halford, W.K., Cronin, T.J., Lyons, A., 2020. Couple relationship
education for same-sex couples: a preliminary evaluation of rainbow CoupleCARE.
J. Couple Relatsh. Ther. 19 (3), 230–249. https://doi.org/10.1080/
15332691.2020.1746458.
Pepping, C.A., Girme, Y.U., Cronin, T.J., MacDonald, G., 2024. Diversity in singlehood
experiences: testing an attachment theory model of sub-groups of singles. J. Pers.
https://doi.org/10.1111/jopy.12929.
Perez, J., Pepping, C.A., 2024. Relationship experiences of transgender and non-binary
adults: exploring dating goals, relationship structures, minority stress, sexual
fetishization, and relationship victimization. International Journal of Transgender
Health. https://doi.org/10.1080/26895269.2024.2316690.
Purol, M.F., Keller, V.N., Oh, J., Chopik, W.J., Lucas, R.E., 2021. Loved and lost or never
loved at all? Lifelong marital histories and their links with subjective well-being.
J. Posit. Psychol. 16 (5), 651–659. https://doi.org/10.1080/
17439760.2020.1791946.
Revenson, T.A., Kayser, K.E., Bodenmann, G.E., 2005. Couples Coping With Stress:
Emerging Perspectives on Dyadic Coping. American Psychological Association.
Rimmer, S.E., Cohn, T.J., Hastings, S.L., Steele, J.C., Woods, C., 2023. Does social
support moderate the relationship between gender minority stress and suicide within
a sample of transgender and gender diverse people? Journal of Gay & Lesbian Mental
Health 27 (3), 284–303. https://doi.org/10.1080/19359705.2021.1997855.
Roberts, B.W., Robins, R.W., 2000. Broad dispositions, broad aspirations: the intersection
of personality traits and major life goals. Personal. Soc. Psychol. Bull. 26 (10),
1284–1296. https://doi.org/10.1177/0146167200262009.
Robles, G., Dellucci, T.V., Gupta, S.K., Rosenthal, L., Starks, T.J., 2022. Identity and
relationship-based discrimination, and mental health in a sample of sexual minority
male couples. Journal of Gay & Lesbian Mental Health 26 (1), 76–97. https://doi.
org/10.1080/19359705.2021.1926389.
Rodriguez, A., Agardh, A., Asamoah, B.O., 2018. Self-reported discrimination in health-
care settings based on recognizability as transgender: a cross-sectional study among
transgender U.S. Citizens. Archives of Sexual Behavior 47 (4), 973–985. https://doi.
org/10.1007/s10508-017-1028-z.
Sarno, E.L., Dyar, C., Newcomb, M.E., Whitton, S.W., 2022. Relationship quality and
mental health among sexual and gender minorities. J. Fam. Psychol. 36 (5),
770–779. https://doi.org/10.1037/fam0000944.
Scott, S.B., Whitton, S.W., Buzzella, B.A., 2019. Providing relationship interventions to
same-sex couples: clinical considerations, program adaptations, and continuing
education. Cogn. Behav. Pract. 26 (2), 270–284. https://doi.org/10.1016/j.
cbpra.2018.03.004.
Struck, N., Krug, A., Feldmann, M., Yuksel, D., Stein, F., Schmitt, S., Meller, T.,
Brosch, K., Dannlowski, U., Meinert, S., Opel, N., Lemke, H., Waltemate, L.,
Nenadi´
c, I., Kircher, T., Brakemeier, E.-L., 2020. Attachment and social support
mediate the association between childhood maltreatment and depressive symptoms.
J. Affect. Disord. 273, 310–317. https://doi.org/10.1016/j.jad.2020.04.041.
Testa, R.J., Habarth, J., Peta, J., Balsam, K., Bockting, W., 2015. Development of the
gender minority stress and resilience measure. Psychol. Sex. Orientat. Gend. Divers.
2 (1), 65–77. https://doi.org/10.1037/sgd0000081.
Testa, R.J., Michaels, M.S., Bliss, W., Rogers, M.L., Balsam, K.F., Joiner, T., 2017.
Suicidal ideation in transgender people: gender minority stress and interpersonal
theory factors. J. Abnorm. Psychol. 126 (1), 125.
Traa, M., De Vries, J., Bodenmann, G., Den Oudsten, B., 2014. Dyadic coping and
relationship functioning in couples coping with cancer: a systematic review. Br. J.
Health Psychol. 20 https://doi.org/10.1111/bjhp.12094.
Valentine, S.E., Shipherd, J.C., 2018. A systematic review of social stress and mental
health among transgender and gender non-conforming people in the United States.
Clin. Psychol. Rev. 66, 24–38. https://doi.org/10.1016/j.cpr.2018.03.003.
Waite, L., Gallagher, M., 2001. The Case for Marriage: Why Married People Are Happier,
Healthier and Better Off Financially. Crown.
Warren, J.C., Smalley, K.B., Barefoot, K.N., 2016. Psychological well-being among
transgender and genderqueer individuals. International Journal of Transgenderism
17 (3–4), 114–123. https://doi.org/10.1080/15532739.2016.1216344.
Weitkamp, K., Feger, F., Landolt, S.A., Roth, M., Bodenmann, G., 2021. Dyadic coping in
couples facing chronic physical illness: a systematic review. Front. Psychol. 12
https://doi.org/10.3389/fpsyg.2021.722740.
Whisman, M.A., 2007. Marital distress and DSM-IV psychiatric disorders in a population-
based national survey. J. Abnorm. Psychol. 116 (3), 638.
Whisman, M.A., Baucom, D.H., 2012. Intimate relationships and psychopathology. Clin.
Child. Fam. Psychol. Rev. 15 (1), 4–13. https://doi.org/10.1007/s10567-011-0107-
2.
Whitton, S.W., Buzzella, B.A., 2012. Using relationship education programs with same-
sex couples: a preliminary evaluation of program utility and needed modications.
Marriage Fam. Rev. 48 (7), 667–688. https://doi.org/10.1080/
01494929.2012.700908.
Whitton, S.W., Weitbrecht, E.M., Kuryluk, A.D., Hutsell, D.W., 2016. A randomized
waitlist-controlled trial of culturally sensitive relationship education for male same-
sex couples. J. Fam. Psychol. 30 (6), 763–768. https://doi.org/10.1037/
fam0000199.
Whitton, S.W., Scott, S.B., Dyar, C., Weitbrecht, E.M., Hutsell, D.W., Kuryluk, A.D., 2017.
Piloting relationship education for female same-sex couples: results of a small
randomized waitlist-control trial. J. Fam. Psychol. 31 (7), 878–888. https://doi.org/
10.1037/fam0000337.
Whitton, S.W., Dyar, C., Newcomb, M.E., Mustanski, B., 2018a. Romantic involvement: a
protective factor for psychological health in racially-diverse young sexual minorities.
J. Abnorm. Psychol. 127 (3), 265–275. https://doi.org/10.1037/abn0000332.
Whitton, S.W., Scott, S.B., Weitbrecht, E.M., 2018b. Participant perceptions of
relationship education programs adapted for same-sex couples. Journal of Couple &
Relationship Therapy 17 (3), 181–208. https://doi.org/10.1080/
15332691.2017.1372835.
Whitton, S.W., Godfrey, L.M., Crosby, S., Newcomb, M.E., 2020. Romantic involvement
and mental health in sexual and gender minority emerging adults assigned female at
birth. J. Soc. Pers. Relat. 37 (4), 1340–1361. https://doi.org/10.1177/
0265407519898000.
Whitton, S.W., Dyar, C., Godfrey, L.M., Newcomb, M.E., 2021. Within-person
associations between romantic involvement and mental health among sexual and
gender minorities assigned female-at-birth. J. Fam. Psychol. 35 (5), 606.
Witcomb, G.L., Bouman, W.P., Claes, L., Brewin, N., Crawford, J.R., Arcelus, J., 2018.
Levels of depression in transgender people and its predictors: results of a large
matched control study with transgender people accessing clinical services. J. Affect.
Disord. 235, 308–315.
Xu, Y., Pace, S., Kim, J., Iachini, A., King, L.B., Harrison, T., DeHart, D., Levkoff, S.E.,
Browne, T.A., Lewis, A.A., Kunz, G.M., Reitmeier, M., Utter, R.K., Simone, M., 2022.
Threats to online surveys: Recognizing, detecting, and preventing survey bots. Soc.
Work Res. 46 (4), 343–350. https://doi.org/10.1093/swr/svac023.
C.A. Pepping et al.
Journal of Aective Disorders 365 (2024) 634–643
643