Mental Health: Gender-based Discrimination Experienced by TGNC Individuals

Olivia Russo

The transgender (i.e., gender identities that do not align with sex assigned at birth) and gender non-conforming (i.e., gender identities existing outside the binary categories of male and female) community (TGNC) is particularly vulnerable to psychiatric problems and disparities in mental health (Brennan et al., 2017; Chozden et al., 2019; Lloyd et al., 2019; Price-Feeney et al., 2020). TGNC individuals are 1.5 to 2 times more likely to experience symptoms of anxiety and depression than nongender minorities (Livingston et al., 2020). Furthermore, relative to cisgender individuals, TGNC individuals are at an increased risk of contemplating and attempting suicide; specifically, as compared to 5% of their cisgender counterparts, 40% of TGNC individuals will have attempted suicide at some point in their lifetime (McDowell et al., 2020; Price-Feeney et al., 2020). Research suggests that discrimination is a key factor that drives these mental health disparities (Gleason et al., 2016; Puckett et al., 2020). TGNC individuals disproportionately experience gender-based discrimination (i.e., prejudice, rejection, and violence based on identity or expression) due to their gender minority status, which may result in elevated levels of anxiety and depression (Brennan et al., 2017; Chodzen et al., 2019; Livingston et al., 2020; Lloyd et al., 2019; Williams & Mann, 2017). Gender-based discrimination exists in two notable forms: daily gender-based discrimination (i.e., everyday occurances of gender-based discrimination) and structural gender-based discrimination (i.e., discrimination in public realms due to lack of protection under policies; Glick et al., 2019; Livingston et al., 2020; Testa et al., 2017; Williams & Mann, 2017). The mechanism through which discrimination affects anxiety and depression is important to investigate, as interventions targeting this mechanism could be the most effective in alleviating anxious and depressed feelings in TGNC individuals. Thus, this review aimed to answer the following question: How does gender-based discrimination impact levels of anxious and depressed moods in TGNC individuals?

Daily Discrimination

Daily gender-based discrimination affects the TGNC community disporportionately through minority stress (i.e., discrimination based on the marginalized social status and systemic oppression of gender minority people; Brennan et al., 2017; Price-Feeney et al., 2020; Puckett et al, 2020). Minority stress exists in two forms: distal stress and proximal stress (Chozden et al., 2019; Testa et al., 2017). Distal stress, or overt gender-based discrimination, includes non-gender affirming external experiences and events, rejection due to gender, and verbal or physical attacks based on gender identity (e.g., harassment, violent assault, microaggressions, social rejection, and sexual and physical violence; Brennan et al., 2017; Lloyd et al., 2019; Testa et al., 2017). Explicit and direct gender-based discrimination is categorized as victimization, which cumulatively can lead to TGNC individuals becoming hypervigilent about future minority stress experiences (Livingston et al., 2020). Hypervigilence to minority stress experiences causes TGNC individuals to be more aware of the plethora of discrimination they experience, which, in turn, furthers sensitivity to these experiences, creating a cyclical relation between stress experiences and sensitivity.

The relation between distal stress and anxious and depressed moods is mediated by proximal stress, or the internalization of psychological processes based on experiences and societal messages about norms (Lloyd et al., 2019; Testa et al., 2017). In other words, when TGNC individuals are exposed to overt forms of discrimination and subtle messages about valid gender expression (i.e., distal stress), they often internalize these experiences in an attempt to process them (i.e., proximal stress; Livingston et al., 2020; Lloyd et al., 2019; Puckett et al., 2020; Testa et al., 2017). This process of internalizing negative experiences might subsequently lead to internalized homophobia/transphobia and internalized stress (Chodzen et al., 2019; Gleason et al., 2016; Lloyd et al., 2019). Research has found that internalized homophobia/transphobia is most damaging to TGNC individuals’ mental health (Lloyd et al., 2019). This internalization is associated with a need to conceal identity and negative self-worth, both of which further psychological distress, and, in turn, exacerbate anxious and depressed moods (Brennan et al., 2017; Livingston et al., 2020; Price-Feeney et al., 2020; Puckett et al., 2020; Testa et al., 2017).

Structural Discrimination

The experiences and effects of daily discrimination are compounded by structural discrimination, further damaging TGNC individuals’ mental health. Structural gender-based discrimination (i.e., policies and laws that do not promote equal rights or address gender identity as an area of discrimination) leaves TGNC individuals lacking legal protection from discrimination (Williams & Mann, 2017). Specifically, 33 out of 50 state nondiscrimination laws do not include gender identity as a category for which to protect against discrimination (Gleason et al., 2016; Kattari et al., 2016; Williams & Mann, 2017). As a result, TGNC individuals in unprotected states experience policy-level gender discrimination, stigma, and victimization in many social domains, including, but not limited to, housing, employment, and medical care (Brennan et al., 2017; Testa et al., 20 2017; Williams & Mann, 2017).

Housing is another notable domain where TGNC individuals lack protection, evidenced by the federal Fair Housing Act (1968), which protects against housing discrimination (e.g., based on race and ability) in all states, but neglects to include gender identity as a category (Kattari et al., 2016). In turn, TGNC individuals disproportionately experience housing discrimination, as compared with their cisgender counterparts (Gleason et al., 2016; Kattari et al., 2016). Specifically, TGNC individuals experience discrimination in acquiring housing, are often denied housing due to their gender identity/expression, and/or encounter discrimination in the form of unfair or unjustified evictions (Gleason et al., 2016; Kattari et al., 2016). Unfortunately, many TGNC individuals do not acquire housing, illustrated by the fact that 19% of TGNC individuals are homeless (Kattari et al., 2016; Testa et al., 2017). Not only are TGNC individuals at a higher risk for homelessness, but they also experience further gender-based discrimination in homeless shelters, which are segreated by binary sex (i.e., male and female; Kattari et al., 2016). The compounding effects of gender-based housing discrimination result in TGNC individuals reporting increased perceptions of stigma against the TGNC community (Gleason et al., 2016). In other words, the more that TGNC individuals experience discrimination in housing, the more they believe that others hold prejudice against them.

TGNC individuals often experience both housing discrimination and elevated levels of employment discrimination as compared to their cisgender counterparts, due to their minority gender identity (Kattari et al., 2016). Specifically, research has found that 78% of TGNC individuals reported maltreatment and discrimination at work due to their gender identity/expression (Testa et al., 2017). Further, they frequently experience discriminatory hiring and firing practices based on their non-binary gender identity; specifically, in one study, 46% of TGNC individuals reported having been fired or denied a promotion (Gleason et al., 2016; Kattari et al., 2016; Testa et al., 2017). These statistics highlight the hostility that TGNC individuals experience in the workplace, not only during hiring and firing practices, but also during regular work-days. In other words, TGNC individuals identify outside the gender binary (i.e., male and female genders), thus possessing a minority identity and leaving them to be victims of gender-based discrimination. In addition to housing being a notable social domain, health and medical care exists as the most prominent social domain where TGNC individuals experience structural discrimination (Brennan et al., 2017; Testa et al., 2017; Williams & Mann, 2017). Both lived experiences of discrimination and the fear of facing discrimination act as barriers to accessing healthcare for TGNC individuals (Glick et al., 2018). Specifically, TGNC individuals report that they often delay seeking medical treatment, and that, when they do, they experience unequal treatment by healthcare professionals in the forms of verbal harassment, physical assault, and explicit treatment refusal (Glick et al., 2018; Testa et al., 2017). The extent to which TGNC individuals are protected by government policies differs by state; however, as of 2018, 30 states in the U.S. lacked state-level healthcare policies protecting TGNC communities (McDowell et al., 2020; Williams & Mann, 2017). For example, Tennessee laws allow counselors to deny service to clients based on personal principles (e.g., the belief that binary sex defines gender; Grzanka et al., 2019). This effectively legalizes discrimination against TGNC individuals and produces differences in access to treatment (Grzanka et al., 2019). Experiences of explicit victimization without legal repercussions negatively impact anxious and depressed moods (Glick et al., 2018; Testa et al., 2017; Williams & Mann, 2017). In addition to denial of treatment, the lack of cultural competency in clinicians results in TGNC individuals receiving unequal treatment, through experiencing microaggressions (i.e., intentional or unintentional derogatory messages) from clinicians, and consequently heightening the risk for anxiety in TGNC clients (Grzanka et al., 2019). Structural gender-based discrimination, most notably in health settings, results in TGNC individuals experiencing victimization in the medical field, which contributes to increased levels of anxious and depressed moods (Brennan et al., 2017; Glick et al., 2018; Testa et al., 2017; Williams & Mann, 2017).

Identity Concealment

Both structural discrimination and daily discrimination (i.e., minority stress) result in elevated levels of depression and anxiety, where discrimination’s impact on depression and anxiety is mediated by identity concealment (Chodzen et al., 2019; Livingston et al., 2020). Identity concealment, or hiding characteristics of one’s identity through changing aspects of appearance and behavior, is developed as a form of protection from real or anticipated threats in an attempt to reduce discrimination (Livingston et al., 2020; Lloyd et al., 2019; Testa et al., 2017). Examples of identity concealment include altering gender expression/appearance, changing vocal intonation, concealing health or HIV status, and/or modifying mannerisms and gestures (Livingston et al., 2020; Lloyd et al., 2019). High levels of identity concealment heightens sensitzation to genderbased discrimination (Livingston et al., 2020; Lloyd et al., 2019). In turn, this produces heightened emotional reactions and maladaptive emotional management and regulation, which leads to psychological distress, further exacerbating anxious and depressed moods (Livingston et al., 2020; Lloyd et al., 2019; Puckett et al., 2020).

In relation to daily discrimination, the effects of minority stress in any form lead to negative psychological internalizations, including engaging in identity concealment (Chodzen et al., 2019; Livingston et al., 2020). More specifically, the most direct result of proximal stress in TGNC individuals is identity concealment (Livingston et al., 2020; Lloyd et al., 2019). Further, distal stress (e.g., victimization and microaggressions) results in psychological internalization and maladaptive coping mechanisms, including engaging in identity concealment (Livingston et al., 2020; Puckett et al., 2020). Identity concealment Gender, Sexuality, & Inequality • 21 Gender-Based Discrimination & TGNC Mental Health 22 is comparable to TGNC individuals’ inability to be authentic, which is associated with feelings of social rejection, shame, and perceived burdensomeness (Testa et al., 2017). Research has found that identity concealment plays an important role in explaining the disparity in mental health outcomes for TGNC individuals (Livingston et al., 2020; Price-Feeney et al., 2020; Puckett et al., 2020; Testa et al., 2017).

Additionally, the lack of protection of TGNC individuals on a structural level in social domains (e.g., housing, employment, medical) predicts increased experiences of psychosocial stressors (i.e., victimization and discrimination), and in turn, increased engagement in identity concelament (Gleason et al., 2016; Livingston et al., 2020). Employment discrimination, in particular, leads to increased perceived stigma, and TGNC individuals’ concealing their identity in the workplace to avoid experiencing this maltreatment (Gleason et al., 2016; Kattari et al., 2016). Further, in relation to medical social domains, genderbased discrimination in the form of non-affirmative treatment (i.e., lack of TGNC identity acknowledgement and acceptance by health care professionals) results in identity concealment in an attempt to avoid unfair treatment (Glick et al., 2018; Testa et al., 2017; Williams & Mann, 2017). Overall, the prominence of psychosocial stressors leads to elevated perceived stigma, which is associated with the internalization of depression and anxiety symptoms and a higher prevalence of suicidality, and engagement in identity concealment, thus heightening levels of anxiety and depression symptoms (Gleason et al., 2016; Livingston et al., 2020; McDowell et al., 2020).

Conclusion

Overall, gender-based discrimination disproportionately affects TGNC individuals’ levels of depression and anxiety symptoms, through the compounded effects of daily and structural gender-based discrimination (Brennan et al., 2017; Chodzen et al., 2019; Gleason et al., 2016; Livingston et al., 2020; Testa et al., 2017). Most notably, this compounded discrimination leads to identity concealment, which further exacerbates depression and anxiety symptoms (Chozden et al., 2019; Livingston et al., 2020). Exploring the relation between gender-based discrimination and levels of anxious and depressed moods allows researchers to address the mental health disparities and attempt to create interventions to reduce this gap. Furthermore, through the exploration of where these disparities exist, interventions to better protect TGNC individuals.

Further research needs to be conducted around the effects of discrimination on TGNC indiviuals, and specifically the effects of identity concealment. Extant research reporting the mental health effects of gender-based discrimination have limitations, including participant recruitment through convenience sampling (Gleason et al., 2016; Grzanka et al., 2019; Testa et al., 2017) and data collection through self-report measures (Glick et al., 2018; Gleason et al., 2016; Livingston et al., 2020). Additionally, these studies lack racially diverse participants, as many samples in the studies discussed comprised of mostly white participants (Chodzen et al., 2019; Grzanka et al., 2019; Hoskin, 2019; Livingston et al., 2020; Puckett et al., 2020; Testa et al., 2017). This important limitation is worth exploring more in future research, as TGNC people of color experience unique, compounded discrimination as a result of intersecting minority identities (Brennan et al., 2017; Glick et al., 2018). Through focusing on intersectionality within the TGNC community, future research on discrimination and identity concealment will be culturally competent, and may be able to lead to possible future interventions to protect these vulnerable groups.

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