Abstract
Purpose:
The aim of this study was to evaluate emotional distress, suicidality, and help-seeking among Israeli transgender and gender diverse (TGD) persons.
Methods:
TGD (n=139) and cisgender (n=275) participants reported on suicidal thoughts and behavior (STB), help-seeking behavior, and emotional distress (General Health Questionnaire [GHQ-12]) in an online survey.
Results:
GHQ-12 and STB were significantly higher among TGD compared with cisgender participants. More TGD participants reported seeking help.
Conclusion:
TGD persons reported high levels of emotional distress and STB, suggesting that their needs for mental health care are not met by the Israeli health services.
Keywords: emotional distress, mental health services, suicidal thoughts and behavior, transgender and gender diverse
Introduction
Transgender and gender diverse (TGD)* people with a gender identity that differs from the one assigned at birth are at high risk for emotional distress. Reports indicate that depressive and anxiety symptoms are consistently elevated among TGD compared with cisgender people (whose gender identity corresponds with the one assigned to them at birth).1 In addition, recent studies reported a high prevalence of suicidal thoughts and behavior (STB) among TGD people, with lifetime suicidal ideation reaching 95%, and suicide attempts of 52%.2–4 These rates are 14–22 times higher compared with the age-adjusted general population.2
Although some of the risk factors for STB in TGD people, such as depression, substance use, sexual and gender abuse, housing instability, and poverty, are similar to the general population,5–7 others are related to gender-based experiences of discrimination.3 These include stigma, family rejection, discrimination, transphobia, and lack of access to gender-affirmative health care.6 Thus, the extremely high prevalence rates may be related to the added effect of discrimination and victimization experiences that have been shown to be independently associated with STB in TGD people.8
Conceptualized in the minority stress theory framework,9 the mental distress of sexual and gender minorities is derived from a hostile or stressful social environment. Thus, the cumulative burden of these stressors leads to poor mental health outcomes, especially in the absence of resilience factors and proper support.1
In Israel, there is a clear lack of comprehensive governmental policy to address relevant mental health issues and access gender-affirmative health resources, reflecting the marginalization of TGD people. Some established policies aim to protect fundamental equality of TGD people, including nondiscriminatory laws, official concordance of identity documentation, specific social welfare services as well as policy papers advising on gender-affirmative health care. However, the awareness and investment of resources to practically tackle issues related to the mental health of TGD people are lacking.
Some of the cultural characteristics of the Israeli society raise difficulties in achieving the aspired change. Specifically, although it may be a more liberal society compared with other countries in the region, Israeli society is conservative, and nourished by military service and war images. At the state level, religious bodies control aspects of individuals' civil rights (i.e., marriage and burial), with negative spillover implications on other rights and liberalism in general.
Having said that, recent years have brought some policy papers and actions to better understand and improve TGD people's mental health specifically, mainly due to grassroots organizations' activism and expertise-based inputs. In this context, a recent report to the Israeli Ministry of Social Affairs indicated that >60% of TGD people reported being diagnosed with anxiety or depression, and 40% reported a lifetime suicide attempt.10 However, to the best of our knowledge, no publication on the mental health of TGD people in Israel has yet been published in peer-reviewed journals.
Since the Israeli TGD community has distinct characteristics rooted in the local culture, this study aims to evaluate the levels of, and the relations between, emotional distress, suicidality, and help-seeking behavior of TGD people, compared with cisgender people in Israel.
Materials and Methods
Sample and procedures
Sample and procedures data were collected using an online questionnaire, which was available from September 1, 2020 to February 15, 2021 (Qualtrics™). TGD participants were recruited through social media with the help of “Ma'avarim,” the largest organization representing the TGD community in Israel. Cisgender participants were also recruited through social media (WhatsApp groups, facebook, and the Academic College of Tel Aviv-Yaffo platform). Where possible, questions were formulated in a gender-neutral language. The study received ethical approval from the Academic College of Tel Aviv-Yaffo (IRB approval no. 2020183). An online informed consent was obtained after a detailed description of the study before filling in the questionnaire.
Gender identity was assessed according to the answers on two questions: (1) “What was your assigned sex at birth”? followed by two exclusive options (boy/girl); (2) “Which of the following would best describe your gender?” followed by four excluding options (man, woman, nonbinary/genderqueer, and other). In case “other” was chosen, the participants were requested to specify their gender identity. Gender identity was defined as TGD if the assigned sex at birth differed from the current gender or the answer to the second question was “nonbinary/genderqueer” or “other.” Gender identity was defined as cisgender if the assigned sex at birth matched the current gender.
Questionnaires
Emotional distress
The 12-item General Health Questionnaire (GHQ-12)11 was used to measure emotional distress in the past 30 days. The questionnaire was translated to Hebrew for the Israeli National Health Survey.12 Participants replied to each item on a 4-point Likert scale ranging from never (0) to frequently (3). The items were summed, and the total scores ranged between 0 and 36, with higher scores representing greater distress. The reliability of GHQ-12 was reported in terms of internal consistency to be α=0.9.13
Suicidal thoughts and behavior
Lifetime and 12-month STB were evaluated using the relevant questions from the Israeli National Health Survey.12 Participants were first asked about suicidal ideation (“Have you ever seriously thought about attempting suicide?”), and those answering “yes” were also asked about suicide plans (“Have you ever made a plan for attempting suicide?”). For those answering “yes” to plans, another question was asked referring to a suicide attempt (“Have you ever attempted suicide?”).
Help-seeking and consultation questionnaire
This questionnaire assesses help-seeking from different sources.14 Participants were asked to report whether they had spoken about their emotional problems with various help resources. These were divided into (1) professional help: general practitioner, internal medicine physician or other medical specialists, psychiatrist, psychologist, and other mental health specialists; (2) nonprofessional help: alternative medicine specialist, self-help group, internet support group, chatroom, religious leader, welfare services, family members, friends and chosen family (possibly relevant for TGD persons), and other resources. With regard to each source, the respondents were asked about lifetime and past 12-month periods (yes/no).
Statistical analysis
Comparisons of the TGD group to the cisgender group were analyzed by sociodemographics, emotional distress, and help-seeking behaviors using chi-square or grouped t-tests, according to the nature of the variables. Univariate logistic regressions were performed to test the associations between gender and lifetime as well as 12-month STB. At the second step, adjusted logistic regression models were performed, including background (age, relationship status, education, religion, and religiosity) and GHQ-12 scores. Covariates were added to the adjusted models if the univariate associations with gender or outcome variables showed a p-level lower than 0.1. Logistic regression outcomes are reported in terms of odds ratio and confidence interval (95% CI). Statistical analyses were conducted using SPSS-25 (IBM, Inc., 2017). In all models, the significance level was set at p<0.05.
Results
The sample included 414 participants, of which 139 identified as TGD (33.6%), 103 (24.9%) cisgender man, and 172 (41.5%) cisgender women. Among TGD participants, 73 (52.5%) identified as binary (47% men and 53% women), and 66 as nonbinary. Since no significant differences in both the background and the measures of this study were found between binary and nonbinary respondents, the results are reported for the pooled TGD group. The respondents' age ranged between 18 and 57 years, with TGD (25.8±8.7) (mean±SD) being slightly older than cisgender respondents (24.7±4.0) (p=0.064). Other demographic characteristics of TGD respondents did not differ from those of cisgender respondents except for religion, as less TGD respondents identified themselves as Jews (Table 1).
Table 1.
Background Characteristics of Transgender and Gender Diverse and Cisgender Respondents
| TGD, n (%) | Cisgender, n (%) | χ2 | |
|---|---|---|---|
| Country of birth (Israel) | 127 (91.4) | 255 (92.7) | 0.2 |
| Religion (Jewish) | 115 (82.7) | 262 (95.3) | 17.8* |
| Religiosity | |||
| Secular | 121 (87.1) | 234 (85.1) | 0.2 |
| Traditional | 15 (10.8) | 34 (12.4) | |
| Religious | 3 (2.2) | 7 (2.5) | |
| Relationship status (single) | 106 (76.3) | 200 (72.7) | 0.5 |
| Education (high school or less) | 95 (69.9) | 182 (66.2) | 0.5 |
p<0.01.
TGD, transgender and gender diverse.
GHQ-12 scores were significantly higher among TGD (19.8±6.5) compared with cisgender respondents (10.9±6.2) (t=13.6, df=412, p<0.001). This outcome remained significant when age was controlled. Since GHQ-12 scores are higher among women than men, we compared the data among cisgender respondents. The outcomes confirmed this assumption (men 9.9±5.7; women 11.4±6.4; p<0.05).
According to help-seeking and consultation questionnaire (HSCQ), more TGD respondents compared with cisgender respondents reported talking to professional and nonprofessional help resources, both lifetime and at 12 months (Table 2). Since background variables did not significantly associate with GHSQ we did not perform adjusted models.
Table 2.
Transgender and Gender Diverse and Cisgender Respondents Who Spoke About Their Emotional Problems with Help Resources According to the Help-Seeking and Consultation Questionnaire
| TGD, n (%) | Cisgender, n (%) | χ2 | |
|---|---|---|---|
| Lifetime | |||
| Professional help | 118 (84.9) | 135 (49.1) | 49.7* |
| Nonprofessional help | 119 (85.6) | 166 (60.4) | 27.4* |
| 12 months | |||
| Professional help | 91 (65.5) | 86 (31.3) | 44.1* |
| Nonprofessional help | 102 (73.4) | 143 (52.0) | 17.4* |
p<0.001.
More TGD respondents reported lifetime and 12-month STB compared with cisgender respondents (Table 3). Both univariate and adjusted models indicated a significantly greater risk for lifetime suicidal ideation, plans, and attempts in TGD compared with cisgender respondents. Although univariate models indicated a greater risk for ideation, plans, and attempts at 12 months in TGD compared with cisgender respondents, the adjusted models indicated a significant difference with regard to ideation and plans, but not attempt.
Table 3.
Associations Between Reports on Lifetime and 12-Month Suicidal Thoughts and Behavior and Gender
| Lifetime STB | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |
Ideation |
Plan |
Attempt |
|||||||||
| n | % | Univariate OR (95% CI) | Adjusted OR (95% CI) | n | % | Univariate OR (95% CI) | Adjusted, OR (95% CI) | n | % | Univariate OR (95% CI) | Adjusted OR (95 CI) | |
| Cisgender | 35 | 12.8 | Ref. | Ref. | 11 | 4.0 | Ref. | Ref. | 6 | 2.2 | Ref. | Ref. |
| TGD | 113 | 81.9 | 30.7** (17.5–53.8) | 29.4** (16.6–52.1)a | 82 | 59 | 34.5** (17.2–68.9) | 32.5** (16.2–65.4)a | 53 | 38.1 | 27.6** (11.4–66.5) | 25.8** (10.6–62.6)a |
| Ideation | 12-month STB Plan | Attempt | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cisgender |
4 |
1.5 |
Ref. |
Ref. |
3 |
1.1 |
Ref. |
Ref |
1 |
0.4 |
Ref. |
Ref. |
| TGD | 62 | 44.6 | 54.5** (19.2–154.6) | 20.8** (6.9–62.8)b | 31 | 22.3 | 26.0** (7.7–86.9) | 9.5* (2.4–37.6)c | 11 | 7.9 | 23.5* (3.0–184.3) | 6.6 (0.6–74.1)d |
p<0.05 **p<0.001
Adjusted for aage, religion; brelationship status, religion, age, GHQ-12; crelationship status, religiosity, age, GHQ-12; dreligiosity, age, GHQ-12.
CI, confidence interval; GHQ-12, General Health Questionnaire; OR, odds ratio; STB, suicidal thoughts and behavior.
Among respondents who reported lifetime suicidal ideation, significantly more TGD (95, 84.1%) than cisgender respondents (20, 57.1%) reported that they ever spoke about their emotional problems with a mental health professional (based on HSCQ) (χ2=11.2, df=1; p<0.001). Although a similar tendency was seen among respondents who reported 12-month suicidal ideation (TGD 38, 71.7%; cisgender 2, 33.3%), the association did not reach significance (χ2=3.6, df=1; p=0.057).
Discussion
The aim of this study was to evaluate emotional distress, suicidality, and help-seeking behavior in the TGD community in Israel. TGD people showed higher emotional distress and greater risk for both lifetime and 12-month STB compared with cisgender people. In addition, more TGD people reported that they talked to both professional and nonprofessional help resources.
Similar to previous reports, the current findings pointed to elevated emotional distress among TGD people.1,15,16 It should be noted that compared with the GHQ-12 norms, emotional distress was high in our study. Specifically, the averages of cisgender men and women were 9.9 and 11.4, respectively, whereas the Israeli National Health Survey 95% CIs for the relevant age group (18–30 years) were 4.6–6.0 and 5.4–7.7, for men and women, respectively.17
This may be related to the fact that data were collected during the second and third waves of COVID-19 in Israel, when lockdowns were forced. During the pandemic, an elevation of mental distress was reported in the general population worldwide, including in Israel.18–20 Although no local study was related to TGD people, reports from other countries show that the restrictions led to worse implications on TGD people, partly due to diminished support systems and lower access to both gender-affirmative and mental health services.21 TGD people were reported to show exacerbations of mental distress, such as heightened levels of anxiety, depression, and STB.21–23
STB rates identified in TGD persons in this study were extremely high with almost 40% reporting a lifetime attempt. These findings align with other reports pointing to an extremely high risk for STB in TGD people.4,7
The finding that more TGD people reported talking to help resources might be surprising since previous reports pointed to barriers to mental health services among TGD people.24 Accordingly, a report to the Israeli Ministry of Social Affairs indicated that almost 80% of TGD respondents reported that they experienced a fear of discriminatory attitudes from health staff, and as a consequence, about 60% avoided receiving the necessary medical treatment, including mental health care.10
In the same line, recent reviews suggest that TGD people often face stigma and discrimination within mental health services25 and encounter incompetent mental health professionals (including those who are unknowledgeable, unnuanced, or unsupportive).24 However, although our findings show that TGD people refer more than cisgender people to mental health services, no data were obtained regarding their experience with mental health services. Thus, the finding that TGD people seek more help does not promise an appropriate response, and in some cases may even exacerbate their distress.26 Further investigation of the quality of mental health care for TGD people is required to answer this question.
Limitations
The major limitation of this study relates to the nonrandom sampling of the participants. Thus, it is possible that people with high distress or STB had a greater tendency to take part in the survey to report their personal difficulties, resulting in elevated distress outcomes, and possibly higher STB rates in TGD participants. However, the resemblance between our findings and other reports does not support such a possibility. In contrast, it is possible that our TGD sample did not represent the more marginalized persons in the community (e.g, homeless people and sex workers), and thus we may have underestimated the levels of distress and STB in the local TGD community.
A second limitation relates to the analysis of the association between mental distress and the tendency to seek help. Owing to the different time frames required to be reported on help-seeking (lifetime and 12 months) and GHQ-12 (30 days), we could not test the associations between these variables. This prevented us from identifying whether TGD people tended to seek for help more than cisgender people at a similar distress level. It is imperative for future studies to take up this point.
A third limitation is derived from the lack of data on the geographical location of the respondents (i.e., rural vs. urban), compromising the generalizability of our results. However, being the main urban area in Israel, it can be assumed that the majority of our sample, as well as most of the TGD community resides in the Tel-Aviv region.
Conclusions
This study indicated high levels of emotional distress and STB in TGD people in Israel. These findings are an initial step to draw attention to the need for suitable mental health services for this population. More specifically, further research should be carried out on mental health care needs and the availability of services for the TGD community in Israel. Identification of needs versus availability can help guide potential policy making and services to improve mental health in the TGD community in Israel.
Acknowledgments
We would like to thank “Maavarim” for their help in the gender-affirmative formulation of the questionnaire, the definition of the appropriate gender classes reported by TGD participants as well as the dissemination of the survey in the community.
Abbreviations Used
- CI
confidence interval
- GHQ-12
General Health Questionnaire
- HSCQ
Help-seeking and Consultation questionnaire
- OR
odds ratio
- STB
suicidal thoughts and behavior
- TGD
transgender and gender diverse
Authors' Contributions
C.B.L., S.H., and G.G. have full access to all the data and are responsible for the integrity of the data and the accuracy of the data analysis. All authors contributed to the study design, collection, analysis, and interpretation of data, drafting the article, and final approval of the version to be published.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
Cite this article as: Bursztein Lipsicas C, Hamdan S, Gal G (2024) Emotional distress, suicidal behavior, and help-seeking among transgender and gender diverse people in Israel, Transgender Health 9:2, 174–179, DOI: 10.1089/trgh.2022.0058.
The term TGD is intended to be inclusive of all transgender (not cisgender) identities including but not limited to transgender, transsexual, gender nonbinary, gender diverse, cross dresser, and gender nonconforming.
References
- 1. Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clin Psychol Rev 2018;66:24–38; doi: 10.1016/j.cpr.2018.03.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Adams NJ, Vincent B. Suicidal thoughts and behaviors among transgender adults in relation to education, ethnicity, and income: A systematic review. Transgend Health 2019;4(1):226–246; doi: 10.1089/trgh.2019.0009 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Bauer GR, Scheim AI, Pyne J, et al. Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in Ontario, Canada. BMC Public Health 2015;15:525; doi: 10.1186/s12889-015-1867-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Dickey LM, Budge SL. Suicide and the transgender experience: A public health crisis. Am Psychol 2020;75(3):380–390; doi: 10.1037/amp0000619 [DOI] [PubMed] [Google Scholar]
- 5. Herman JL, Brown TNT, Haas AP. Suicide Thoughts and Attempts Among Transgender Adults: Findings from the 2015 U.S. Transgender Survey. The Williams Institute, UCLA School of Law: Los Angeles, CA, USA; 2019. Available from: https://williamsinstitute.law.ucla.edu/publications/suicidality-transgender-adults [Last accessed: February 18, 2022]. [Google Scholar]
- 6. Blackmore ER, Munce S, Weller I, et al. Psychosocial and clinical correlates of suicidal acts: Results from a national population survey. Br J Psychiatry 2008;192(4):279–284; doi: 10.1192/bjp.bp.107.037382 [DOI] [PubMed] [Google Scholar]
- 7. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex 2011;58(1):10–51; doi: 10.1080/00918369.2011.534038 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. J Homosex 2006;51(3):53–69; doi: 10.1300/J082v51n03_04 [DOI] [PubMed] [Google Scholar]
- 9. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129(5):674–697; doi: 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Goldin S. Characteristics and needs of the trans community in Israel highlighting health and social services topics: Summary of country-wide survey. Tel Aviv: Levinsky clinic, Israeli Ministry of Health 2020. (Hebrew). Available from: https://www.maavarim.org/_files/ugd/e46647_f3c6b66ce6d84f0f851bff47eec4c791.pdf [Last accessed: February 18, 2022].
- 11. Goldberg DP, Gater R, Sartorius N, et al. The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychol Med 1997;27(1):191–197; doi: 10.1017/s0033291796004242 [DOI] [PubMed] [Google Scholar]
- 12. Levinson D, Zilber N, Lerner Y, et al. Prevalence of mood and anxiety disorders in the community: Results from the Israel National Health Survey. Isr J Psychiatry Relat Sci 2007;44(2):94–103. [PubMed] [Google Scholar]
- 13. Hankins M. The reliability of the twelve-item general health questionnaire (GHQ-12) under realistic assumptions. BMC Public Health 2008;8:355; doi: 10.1186/1471-2458-8-355 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Daeem R, Mansbach-Kleinfeld I, Farbstein I, et al. Barriers to help-seeking in Israeli Arab minority adolescents with mental health problems: Results from the Galilee study. Isr J Health Policy Res 2019;8(1):45; doi: 10.1186/s13584-019-0315-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: A review. Lancet 2016;388(10042):412–436; doi: 10.1016/S0140-6736(16)00684-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Reisner SL, Hughto JMW. Comparing the health of non-binary and binary transgender adults in a statewide non-probability sample. PLoS One 2019;14(8):e0221583; doi: 10.1371/journal.pone.0221583 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Gal G, Levav I, Gross R. Psychopathology among adults abused during childhood or adolescence: Results from the Israel-based World Mental Health Survey. J Nerv Ment Dis 2011;199(4):222–229; doi: 10.1097/NMD.0b013e31820c7543 [DOI] [PubMed] [Google Scholar]
- 18. Hawke LD, Barbic SP, Voineskos A, et al. Impacts of COVID-19 on youth mental health, substance use, and well-being: A rapid survey of clinical and community samples. Can J Psychiatry 2020;65(10):701–709; doi: 10.1177/0706743720940562 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Liang L, Ren H, Cao R, et al. The effect of COVID-19 on youth mental health. Psychiatr Q 2020;91:841–852; doi: 10.1007/s11126-020-09744-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Gilbar O, Gelkopf M, Berger R, et al. Risk factors for depression and anxiety during COVID-19 in Israel: A two-wave study before and during the pandemic. Stress Health 2022. [Epub ahead of print]; doi: 10.1002/smi.3127 [DOI] [PubMed]
- 21. Hawke LD, Hayes E, Darnay K, et al. Mental health among transgender and gender diverse youth: An exploration of effects during the COVID-19 pandemic. Psychol Sex Orientat Gend Divers 2021;8(2):180–187; doi: 10.1037/sgd0000467 [DOI] [Google Scholar]
- 22. Jarrett BA, Peitzmeier SM, Restar A, et al. Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people. PLoS One 2021;16(7):e0254215; doi: 10.1371/journal.pone.0254215 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Wang Y, Pan B, Liu Y, et al. Health care and mental health challenges for transgender individuals during the COVID-19 pandemic. The Lancet Diabetes Endocrinol 2020;8(7):564–565; doi: 10.1016/S2213-8587(20)30182-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Snow A, Cerel J, Loeffler DN, et al. Barriers to mental health care for transgender and gender-nonconforming adults: A systematic literature review. Health Soc Work 2019;44(3):149–155; doi: 10.1093/hsw/hlz016 [DOI] [PubMed] [Google Scholar]
- 25. Rees SN, Crowe M, Harris S. The lesbian, gay, bisexual and transgender communities' mental health care needs and experiences of mental health services: An integrative review of qualitative studies. J Psychiatr Ment Health Nurs 2021;28(4):578–589; doi: 10.1111/jpm.12720 [DOI] [PubMed] [Google Scholar]
- 26. Kattari SK, Bakko M, Hecht HK, et al. Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults. SSM Popul Health 2020;10:100525; doi: 10.1016/j.ssmph.2019.100525 [DOI] [PMC free article] [PubMed] [Google Scholar]