Gender-concordant IDs improve mental health, reduce suicidal thoughts among transgender individuals
Access to identity documents that reflected transgender individuals’ identified gender helped to improve their mental health and reduced suicidal thoughts, according to results of a cross-sectional observational study published in The Lancet Public Health.
“Only 11% of transgender individuals had their preferred name and gender markers on all IDs, but this group saw a marked reduction in serious psychological distress and suicide ideation,” Ayden Scheim, PhD, assistant professor of epidemiology and biostatistics at Drexel University Dornsife School of Public Health, told Healio Psychiatry. “Expanding access to gender-concordant IDs for transgender individuals may play a part in helping to reduce the high levels of psychological distress and suicidality in this population.”
According to Scheim and colleagues, those whose IDs differ from their gender presentation experience significant rates of denied access to services, harassment, violence or all three. However, little research exists regarding the health effects of legal gender recognition for this population. Because IDs are required for immigration, security clearances, Social Security applications and other major structural access points, as well as in daily activities, they can be considered a structural determinant of health associated with socioeconomic-political context, the researchers wrote.
To determine whether having gender-concordant IDs was associated with mental health, Scheim and colleagues obtained data of 27,715 participants in the 2015 U.S. Transgender Survey — the largest cross-sectional survey of transgender adults in the United States. The researchers included individuals aged 18 years or older who resided in a U.S. state, territory or overseas U.S. military base and considered themselves transgender, trans, nonbinary, genderqueer or similar. They excluded those not living day-to-day in a different gender to the sex they were assigned at birth, those who identified as crossdressers and those missing data. Whether all or some (vs. none) of a participant’s IDs reflected their preferred gender marker and name served as the primary exposure of interest. Specifically, Scheim and colleagues used the Kessler 6 scale to examine associations between psychological distress and suicide ideation, planning and attempts in the past year, which they analyzed using linear and modified Poisson regression models to examine associations with participants’ IDs.
In their analytic sample, the researchers included 22,286 participants, of whom 10,288 (weighted percentage, 45.1%) had their preferred gender marker and name on none, 9,666 (44.2%) on some and 2,332 (10.7%) on all of their IDs. Adjusting for potential confounders, participants for whom all IDs were concordant had lower prevalence of serious psychological distress (adjusted prevalence ratio = 0.68; 95% CI, 0.61-0.76), suicidal ideation (0.78; 95% CI, 0.72-0.85) and suicide planning (0.75; 95% CI, 0.64-0.87) compared with those with no gender-concordant ID. Individuals with some vs. no concordant IDs experienced generally smaller reductions in suicidality and distress. Further, the researchers found no association between gender-concordant ID and suicide attempts (ie, adjust prevalence ratio for all vs. no IDs, 0.92; 95% CI, 0.68-1.24).
“Processes for changing one’s name or gender marker on IDs can be very hard to navigate, with wide policy variation across jurisdictions and between state and federal IDs,” Scheim told Healio Psychiatry. “Health care providers also play an important role in the process because a physician’s letter is generally required to change the gender marker. Clinicians can familiarize themselves with relevant local guidelines (available from the National Center for Transgender Equality), assess their client’s/patient’s needs around legal gender affirmation and then support them with the process as appropriate.”
In a related editorial, Monica Malta, MPH, PhD, assistant professor of equity, gender and population in the department of psychiatry at University of Toronto, and colleagues offered additional initiatives that would benefit this patient population.
“The study is highly relevant to efforts to improve the health and well-being of transgender populations,” they wrote. “We hope that the results will encourage governments worldwide to remove barriers to gender-congruent IDs for [transgender] people. Although such initiatives will probably improve mental health disparities experienced by this population, more work needs to be done. We must also address the multitude of other factors contributing to these disparities, including the high rates of violence and discrimination, limited access to gender-affirming medical, surgical, and mental health care, and a litany of minority stressors experienced by [transgender] populations. – by Joe Gramigna
Disclosures: The study authors and editorial authors report no relevant financial disclosures.