Mental health needs of transgender & gender diverse individuals

Issues

• There is some evidence that TGD individuals and households on average receive lower incomes and experience higher rates of poverty than non-TGD individuals and households (National Academy of Sciences, 2011).
• The 2015 U.S. Transgender Survey reported that one-third of TGD adults were living in poverty. It also reports 39% of TGD individuals believe they were not hired due to their gender identity and forty-three percent believe they were fired for their gender identity.
• Poverty and financial worries can be linked to an increase in psychological distress and can contribute to the development of anxiety, depression, and trauma (Ridley et al., 2020; Ryu & Fan, 2022).

Actions occupational therapy practitioners/professionals (OTPs) can take:

• Help TGD individuals develop their vocational skills, increase their self-advocacy and self-efficacy, and identify safe workplaces.
• Identify social supports and communities that TGD individuals may be able to utilize.
• Advocate for the enforcement of anti-discrimination policies within business
• Provide education on inclusive environments to businesses.

Issues

• Students who identify as TGD are more likely to experience discrimination and bullying when compared to their cisgender peers.
• This victimization contributes to negative physical and mental health outcomes as well as having a negative influence on personal development.
• School environment, family, social environment, and other sociodemographics are all factors that influence the rate of victimization of TGD students (Martín-Castillo et al., 2020).

Actions occupational therapy practitioners/professionals (OTPs) can take to advocate for TGD students:

• Participate in school sports and clubs.
• Use preferred restrooms.
• Choose what name and pronouns to use at school.
• Have access to and participate in occupations.

Issues

• Negative experiences can have a negative impact on mental health and discourage TGD individuals from seeking medical care.
• Negative health experiences occur when:
  • TGD individuals are refused care
  • Healthcare professionals refuse to touch them or use excessive precautions (i.e., extra gloves, mask, etc.) when providing care.
  • Use harsh or abusive language.
  • Blame TGD for their health status.
  • Are physically rough or abusive (James et al., 2015; Lambda Legal, 2010).

Actions occupational therapy practitioners/professionals (OTPs) can take:

• Educate themselves on TGD barriers.
• Advocate for the enforcement of anti-discrimination policies.
• Provide education to staff.
• Create programs that are safe for TGD clients.

Issues

• TGD individuals experience being unhoused and unsheltered at a disproportionate rate when compared to their non-TGD peers.
• TGD individuals of colors, TGD youth, and TGD youth of color specifically are at an increased risk (Fraser et al., 2019; National Alliance to End Homelessness, 2020; Ormiston, 2022).
• The experience of being unhoused or unsheltered can lead to an increased risk of complex trauma, mental and physical health issues, and socioemotional issues (Helfrich & Synovec, 2019; Kirby et al., 2023).

Actions occupational therapy practitioners/professionals (OTPs) can take:

• Consider the impact on occupations that being unhoused can have.
• Recognize beneficial TGD life-skills training.
• Advocate for safe and inclusive shelters, community-centers, and public services.

Issues

• Lack of familial support due to gender identity may increase the risk of mental health concerns in TGD youth (Pariseau et al., 2019). TGD older adults are at a higher risk for social isolation, neglect, and mental health concerns (Knauer, 2016).
• The TGD community is one subgroup of the wider lesbian, gay, bisexual, transgender, queer, intersex, and a-sexual/romantic (LGBTQIA) community.
• TGD individuals may also be part of other social networks with things in common such as hobbies, performance, spirituality, religiosity, or activism.
• Connection to a supportive community helps build resilience, reduce stress, and cope with discrimination and stigma (Singh et al., 2011).

Actions occupational therapy practitioners/professionals (OTPs) can take:

• Assist TGD clients with finding different safe social networks and welcoming communities within their neighborhoods.
• Advocate for the inclusion of TGD individuals in community programs, public events, and private functions.

• Institutional environments refer to any facility or organization in which people reside and receive care in a congregate or group setting (Coleman et al., 2022).
• This can include but is not limited to:
  • Inpatient facilities
  • Long-term care facilities
  • Palliative care
  • Assisted living facilities
  • Correctional facilities
  • Detention centers
  • Jails (Coleman et al., 2022)
• TGD individuals who reside in institutional settings have a right to receive appropriate healthcare services including TGD-specific mental and medical care (Coleman et al., 2022).
• Disparities faced by TGD individuals within institutional settings include being denied access to:
  • Timely care
  • Desired clothes
  • Grooming objects
  • Private showers
  • Toileting facilities
  • Safe and appropriate housing (Coleman et al., 2022)
• OTP’s hold a unique ability to work throughout the various types of institutional settings by:
  • Addressing mental health concerns within those facilities.
  • Addressing occupational injustice faced by TGD individuals.
  • Advocating for the right to participate in meaningful occupations.

• Gender dysphoria is the emotional distress experienced when there is a misalignment of one’s physical body and perceived gender with the inner sense of self (Keuroghlian et al., 2022).
• It is important to note that gender dysphoria is not:
  • Experienced by every TGD individual.
  • Required for an individual to identify as transgender or gender diverse (Coleman et al., 2022).
• Individuals who experience gender dysphoria may be at higher risk of developing a mental illness. Gender-affirming interventions can help promote health and well- being of TGD clients and reduce the discomfort and distress that is often experienced with gender dysphoria (Coleman et al., 2022).
• OTPs can support TGD clients who experience gender dysphoria by:
  • Promoting engagement in and teaching gender-affirming occupations (dressing, health management, etc.).
  • Advocating for equal access to gender-affirming occupations.
• Understanding the trans-specific stress factors that can negatively impact TGD client’s mental health can help inform interventions through a gender affirmative approach (Austin & Craig, 2015).
• OTPs can refer to the American Occupational Therapy Association’s (AOTA) professional policy, Affirming Gender Diversity and Identity (American Occupational Therapy Association, 2021), to identify the targeted outcomes set forth by AOTA.
• The World Professional Association for Transgender Health Standards of Care Version 8 also proposes principles for working with TGD clients in statement 2.5 that are supported by AOTA’s professional policy (Coleman et al., 2022).

• There are challenges in differentiating between a clinical eating disorder and disordered eating due to gender dysphoria and research on true clinical eating disorders among TGD individuals is lacking (Keuroghlian et al., 2022).
• The DSM-5 criteria for clinical eating disorders were developed based on female presentation, making it difficult to apply the criteria to TGD individuals (Coelho et al., 2019).
• TGD individuals may be at a greater risk for anorexia nervosa and bulimia nervosa and TGD youth are at an increased risk of developing eating disorders when compared to non-TGD youth (Coelho et al., 2019; Keuroghlian et al., 2022).
• Body image concerns (i.e., body hatred, body dissatisfaction, body aversion) are one of the primary factors for eating disorders among TGD individuals (Keuroghlian et al., 2022).
• Understanding how body image disorders intersect with gender identity and eating disorders can help an OTP understand how their TGD client’s physical self affects their self-esteem, self-concept, and sense of autonomy.
• OTPs can support TGD individuals by promoting mindfulness or meditation, building healthy habits and routines, promoting community connections, and encouraging healthy hobbies (Lock & Pépin, 2019).

• TGD individuals who are also Black, Indigenous, or People of Color (BIPOC) experience higher rates of:
  • Discrimination
  • Harassment
  • Violence
  • Gender minority stress
  • Racial minority stress
  • Physical health disparities
  • Mental health disparities (Howard et al., 2019; Coleman et al., 2022)
• The dynamic relationship of systemic racism and transphobia exacerbates the occupational injustice and mental health disparities faced by these individuals as well as access to educated and affirming mental health providers (Howard et al., 2019).
• While some communities are reported to have lower rates of utilizing mental health services, it should not be assumed that this is entirely due to cultural differences and may be due to health access inequality (Becerra et al., 2021).
• OTPs should be aware that some mental health approaches, such as cognitive behavioral therapy (CBT), may not be the best practice for clients of color since CBT has been primarily researched and used for white, cisgender individuals (Iwamasa & Hays, 2019).
• OTPs should work to create inclusive and culturally-sensitive environments while advocating for current best practices.

• TGD individuals face gender minority stress, which is chronic stress caused by experiences of stigma, discrimination, and violence that have a social basis in structural, institutional, and policy-level conditions (Keuroghlian et al., 2022)
• These experiences of stigma, prejudice, discrimination, harassment, and violence can be perpetuated by:
  • Individuals
  • Groups
  • Private and public entities
  • States
  • Governments
• Gender minority stress is associated with poor physical health and increased rates of anxiety, depression, non-suicidal injuries, and suicidal ideation and behaviors (Coleman et al., 2022).
• The gender minority stress model (Testa et al., 2015) can be utilized in interventions to guide an understanding of potential stressors and resiliency factors a TGD client might experience.

• The overall disability rate for TGD individuals is nearly double that of non-TGD individuals (Smith-Johnson, 2022). TGD also has a higher diagnosis rate of autism spectrum disorder (3-6 times more likely than cisgender peers) as well as other neurodevelopmental and psychiatric conditions (Warrier et al., 2020).
• Disabled adults often face ableism, discrimination against those with a disability, within their workplaces and in the community. Ableism negatively impacts mental health and can cause increased rates of mental distress (Cree et al., 2020).
• Those who experience both transphobia and ableism may be at an increased risk of mental health concerns.
• While there is limited literature discussing the intersection of disability and being TGD, autistic individuals have reported healthcare providers invalidating their gender due to their autism diagnosis (Kirby et al., 2023; Shapira & Granek, 2019).
• OTPs can support TGD with disabilities by affirming their gender, supporting engagement in meaningful occupations, and advocating for their client’s autonomy.

• TGD individuals often face adversities in different forms and in different aspects of their lives.
• Although not every individual may perceive and feel trauma experiences in the same way, TGD individuals can face trauma on a historical, cultural, community, and individual basis (Neumann et al., 2021).
• An OTP who is trauma-informed can support TGD clients who may have experienced an adverse event or feel hesitant to confide in healthcare providers.
• By using a trauma-informed care approach with all clients, OTPs can understand the impact that adverse events may have on a client’s occupational performance and avoid re-traumatizing clients during therapy (Gibbs & Qureshi, 2023).

• OTPs can assist transgender clients in identifying trans-specific minority stressors, how they correlate with internal and external stigma, and identify sources of resilience for well-being (Austin & Craig, 2015).

• TA-CBT is an adaptive version of CBT that has been developed to meet the unique needs of transgender clients. TA-CBT can help transgender clients with:
  • maladaptive behaviors (substance abuse, isolation, self-harm, etc.)
  • negative attitudes
  • negative thoughts
  • transphobic beliefs
  • learning healthier coping strategies (Austin & Craig, 2015)
• OTPs can integrate TA-CBT techniques into their treatment sessions to provide healthier coping strategies, promote agency and self-efficacy, and encourage self-compassion and hope.
• OTPs should work to understand trans-specific stress (discrimination, alienation, transphobia, gender dysphoria, systematic oppression, etc.) and create an environment that is affirming, trauma-informed, and provides sources of resiliency (Austin & Craig, 2015).