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. Author manuscript; available in PMC: 2025 Dec 16.
Published in final edited form as: J Psychiatr Res. 2025 Oct 1;191:554–560. doi: 10.1016/j.jpsychires.2025.09.075

Internalized transphobia and psychological distress among transgender and gender non-confirming emerging adults: The mediating roles of social support and gender identity disclosure

Chenglin Hong a,b,*, Tural Mammadli c, Elizabeth SC Wu d, Ian W Holloway d
PMCID: PMC12704365  NIHMSID: NIHMS2127425  PMID: 41072305

Abstract

Transgender and gender non-conforming (TGNC) individuals encounter distinct challenges that can significantly impact their psychological well-being. Among these challenges, internalized transphobia —where individuals internalize societal stigma related to their gender identity—emerges as a critical stressor potentially exacerbating psychological distress. This study aims to explore these mechanisms by examining how social support and gender identity disclosure indirectly affect the relationship between internalized transphobia and psychological distress among TGNC emerging adults. Data for this secondary analysis were drawn from a study among emerging adults aged 18–29 in California. Recruitment occurred between 2020 and 2021 through a combination of online and offline methods. The current analysis focused on TGNC participants (n = 270), assessing internalized transphobia with an adapted scale (alpha = 0.92), psychological distress with the Kessler K6 scale (alpha = 0.90), social support using the Multidimensional Scale of Perceived Social Support (alpha = 0.92), and gender identity disclosure with a modified concealed sexual identity scale (alpha = 0.85). Path analyses were conducted using RStudio. Participants had a mean age of 22.9 years (SD = 3.1) and 58.9 % screened positive for psychological distress. Internalized transphobia showed a positive correlation with psychological distress (r = 0.14, p < 0.05) and negative correlations with both outness (r = −0.49) and social support (r = −0.22). Path analyses revealed that both social support and gender identity disclosure indirectly affected the association between internalized transphobia and psychological distress. Our findings underscore the profound impact of internalized transphobia on psychological distress among TGNC individuals. Social support partially mitigates the negative effects of internalized transphobia, while greater outness significantly buffers psychological distress. These insights highlight the necessity of interventions that not only address internalized stigma but also bolster social support networks and encourage visibility. Enhancing these areas can significantly improve mental health outcomes for TGNC individuals, emphasizing the need for comprehensive and supportive approaches in mental health strategies.

Keywords: Internalized transphobia, Social support, Psychological distress, Gender identity disclosure, Gender minority stress and resilience model

1. Introduction

Transgender and gender nonconforming (TGNC) persons experience high rates of mental health vulnerabilities, including psychological distress, with literature indicating higher rates compared to cisgender persons (Bazzi et al., 2018; Bockting et al., 2013; Crissman et al., 2019; Fuller and Riggs, 2018; Robertson et al., 2021; Wilson et al., 2016). A study examining mental health outcomes among nearly 550, 000 college students in the U.S. found higher odds of depression, anxiety, eating disorders, and panic attacks among TGNC college students contrasted with their cisgender counterparts (Oswalt and Lederer, 2017). Studies to-date have implicated stigmatizing experiences, such as discrimination and violence, in disproportionately higher levels of mental health concerns and distress reported by TGNC persons (Becerra et al., 2021; Bockting et al., 2013; McDowell et al., 2019; Wilson et al., 2016). For instance, a study of 216 transfeminine youth found higher levels of discrimination was associated with a 3.6-times higher risk of experiencing mental distress (Wilson et al., 2016), highlighting the need to identify key factors associated with increased risk of mental health burdens among TGNC individuals and design targeted interventions that address these challenges. Identification of such factors presents a particularly pressing concern for TGNC young adults as evidenced by growing prevalence of mental health challenges experienced by TGNC persons in this age group, including in depressive symptoms, anxiety, and mental distress (Feir and Mann, 2024; Kerr et al., 2024).

According to the Gender Minority Stress and Resilience Model (GMSRM) (Hendricks and Testa, 2012), external stigmatizing events experienced by TGNC persons, such as transphobic discrimination, represent a type of distal minority stressor. GMSRM is rooted in Brooks’s (1981) theory of minority stress (Brooks, 1981) describing lesbian women’s stressful experiences followed by Meyer’s Minority Stress Model describing sexual orientation related stress experiences of gay men and sexual minorities (Meyer, 2003; Moradi et al., 2023). The GMSRM contends distal minority stressors have the potential to impact mental wellbeing. One way distal stressors are proposed to act on wellbeing is through internalization of stressors, in the form of proximal minority stressors. Proximal stressors are distinguished from distal ones due to their internal and personal nature. Numerous proximal stressors are proposed by the GMSRM. One proximal stressor, internalized transphobia, reflects a process by which TGNC persons come to identify with stigmatizing attributes ascribed to their own minoritized gender identities (Rood et al., 2017; Scandurra et al., 2018; Testa et al., 2015). Internalized transphobia is further classified as vertical and horizontal, describing internalized transphobia against the self and other community members, respectively (Rood et al., 2017). Studies suggest internalized transphobia may have a critical role in the relationship between stigmatizing events and poorer mental wellbeing (Azam and Ayub, 2023; Barr et al., 2022; Scandurra et al., 2018), in addition to independently being linked to poorer mental health (Barr et al., 2022; Conn et al., 2023; Garro et al., 2022; Lee et al., 2020; Mann et al., 2023; Perez-Brumer et al., 2015; Rood et al., 2017). Although growing literature has examined the role of distal stressors on the wellbeing of TGNC persons, literature exploring proximal processes, including internalized transphobia, has only started to receive attention recently. Studies linking internalized transphobia and poorer mental wellbeing are critical in elucidating the deleterious role of internalized transphobia. Yet, the underlying mechanisms connecting internalized transphobia to poorer mental wellbeing remain severely understudied. Given literature indicates internalized transphobia presents a particularly potent threat to the mental wellbeing of TGNC persons (Garro et al., 2022; Hendricks and Testa, 2012; Osmetti et al., 2024), it is critical to explore the mechanisms that influence the relationship between internalized transphobia and mental health outcomes among this population.

One such potential factor may be social support, which has been identified as a stress-mediating mechanism in the psychological mediation framework that may help explain the relationship between internalized transphobia and adverse mental health outcomes (Meyer, 2003). Higher levels of social support among TGNC persons are consistently associated with with improved mental wellbeing (Lefevor et al., 2019; London-Nadeau et al., 2023; Pflum et al., 2015; Puckett et al., 2019; Trujillo et al., 2017). It is plausible that individuals experiencing lower levels of internalized stigma may be more open to receiving and benefiting from social support, while those with higher internalized transphobia may experience disruptions in accessing or utilizing such support (Garro et al., 2022; Puckett et al., 2019; Trujillo et al., 2017). Thus, social support may function as a psychological mechanism by which internalized transphobia impacts mental health outcomes and indirectly affects this association. Conversely, internalized transphobia may also play a role in shaping one’s engagement with supportive communities. For instance, TGNC persons experiencing greater internalized stigma may be more likely to distance themselves from affirming individuals or communities, thus limiting their access to potentially protective social resources (Scandurra et al., 2018).

Further, gender identity nondisclosure, a proximal minority stressor referring to the decision to conceal one’s gender identity, may also illuminate important pathways between internalized transphobia and psychological distress. Non-disclosure of gender minority identities can play a critical survival function for TGNC persons, considering substantial stigmatization and limited nature of protections afforded to individuals with minoritized gender identities (Inderbinen et al., 2021). Simultaneously, non-disclosure of one’s sexual or gender minority identities can prove costly for the mental wellbeing of TGNC persons (Osmetti et al., 2024; Owens et al., 2023; Pachankis et al., 2020), as it may be indicative of fear or expectation of rejection, stigma, or violence upon disclosure. Such limitations to outward expression of one’s identity are also inextricably connected to other proximal factors including internalized transphobia (Inderbinen et al., 2021; Owens et al., 2023). Given the close theoretical links between nondisclosure and internalized stigma, it is possible that internalized transphobia influences disclosure decisions, which in turn impact mental health. Furthermore, disclosure may increase access to affirming support networks, which can buffer against minority stress and promote mental well-being (Osmetti et al., 2024).

1.1. The current study

Evidence points to a nuanced relationship between TGNC person’s levels of internalized transphobia, decisions around disclosure of their gender identities, and social support. While growing research has examined the relationship between internalized transphobia and psychological distress among TGNC persons (Lloyd et al., 2019; Timmins et al., 2017), our understanding of whether factors such as disclosure and social support may be important mechanisms that play a role in how internalized transphobia operates on adverse mental wellbeing is limited. This remains especially so for TGNC young adults, who are experiencing a growing prevalence of mental health challenges. Therefore, the current analysis aims to, first, examine the association between experiencing internalized transphobia and psychological distress among a sample of TGNC emerging adults, and secondly, to explore the indirect effects of social support and gender identity disclosure in the relationship between internalized transphobia and psychological distress. Our hypotheses are as follows:

  1. Higher levels of internalized transphobia are associated with higher levels of psychological distress.

  2. Social support indirectly affects the relationship between internalized transphobia and psychological distress.

  3. Gender identity nondisclosure indirectly affects the relationship between internalized transphobia and psychological distress.

The results of the study could provide valuable insights to inform the design and development of future interventions and policies to support the mental health and well-being of TGNC individuals.

2. Methods

2.1. Study procedure and data collection

Data for this secondary data analysis were derived from a Tobacco-Related Disease Research Program (TRDRP) study that examined tobacco and cannabis use disparities among a large sample of emerging adults aged 18 to 29 living in California. A complete description of the parent study was published elsewhere (Krueger et al., 2023). Briefly, emerging adults 18–29 years old residing in California were recruited to complete a survey assessing tobacco use and a series of health and mental health outcomes related to sexual and gender identities. Recruitment occurred between 2020 and 2021 using a combination of online and offline recruitment methods. For the current analysis, we included only individuals who self-identified as transgender or gender non-conforming (TGNC), based on their response to a gender identity item asking: “If you had to choose only one of the following terms, which best describes your current gender identity?” Participants who selected transgender male/man, transgender female/woman, genderqueer/gender non-binary/gender non-conforming/gender fluid, or who wrote in a TGNC identity under gender identity not listed here were included in the analytic sample. Those identifying as cisgender male/man or cisgender female/woman were excluded. All study materials and procedures were reviewed and approved by the Institutional Review Board at the University of California Los Angeles.

2.2. Measures

Internalized transphobia

We measured internalized homophobia using an adapted internalized transphobia scale (Bockting et al., 2020). The original Transgender Identity Survey measures four sub-constructs including pride, passing, alienation, and shame. The current study utilized the subscale assessing pride including 8 questions such as “My gender identity or expression makes me feel special and unique”, “It is okay for me to have people know that my gender identity is different from my sex assigned at birth”, and “I am proud to be a person whose gender identity is different from my sex assigned at birth”, etc. The Likert scale consists of 5 options ranging from (1) strongly disagree to (5) strongly agree. These 8 items were reverse scored and a mean score was calculated, with a high value indicating a higher level of internalized transphobia. The Cronbach’s alpha of the scale among our participants was 0.92, indicating excellent internal consistency.

Psychological distress

We assessed psychological distress using the Kessler 6 (K6) scale (Kessler et al., 2002). The 6-item scale assesses the frequency of non-specific psychological distress, with the choosing options ranging from “none of the time” coded 0 to “all of the time” coded to 4. Participants were asked to rate how often they felt nervous, hopeless, restless or fidgety, so depressed that nothing could cheer them up, that everything was an effort, and worthless in the past 30 days. A total score of the 6 items were calculated and dichotomized into a dummy variable when a total score was equal to or greater than 13 as utilized in previous studies (Hong et al., 2023; Kessler et al., 2002). The Cronbach’s alpha of the K6 scale among the study participants was 0.90, suggesting excellent internal consistency.

Social support

We measured social support using the Multidimensional Scale of Perceived Social Support (MSPSS) (Hong et al., 2023; Zimet et al., 1988). The MSPSS assessed three sources of support, family, friends, and significant others. Questions include “There is a special person who is around when I am in need”, “My family really tries to help me”, and “I can count on my friends when things go wrong”. The 12-item scales were measured using a Likert scale from 1 = very strongly disagree to 7 = very strongly agree, and a mean score of the 12 items was calculated with higher scores indicating higher levels of perceived social support. The Cronbach’s alpha of the MSPSS was 0.92, indicating excellent internal consistency.

Gender identity disclosure

We measured gender identity disclosure using a modified concealed sexual identity scale (Meyer et al., 2002). This scale comprised five questions prompting participants to indicate the extent to which they disclosed their gender identity to their family, LGB friends, straight friends, co-workers, and healthcare providers. We modified the response options to a 4-point Likert scale ranging from 1 (“none”) to 4 (“all”). A mean score was calculated across the items, with higher scores indicating greater overall gender identity disclosure. The scale demonstrated high to excellent internal consistency among our study participants, with a Cronbach’s alpha of 0.85.

Sociodemographic characteristics

The survey also collected participant’s sociodemographic characteristics including age, highest level of education, racial and ethnic backgrounds, relationship status, income level, and housing status. A complete list of sociodemographic and behavioral characteristics was presented in Table 1.

Table 1.

TGNC psychological distress by participant’s characteristics (n = 270).

Yes No Total p-value
Age 22.8 (3.1) 23.2 (2.9) 22.9 (3.1) 0.255
Gender identity 0.084
 Transgender male/man 21 (18.9 %) 23 (14.5 %) 44 (16.3 %)
 Transgender female/woman 21 (18.9 %) 16 (10.1 %) 37 (13.7 %)
 Gender non-conforming 67 (60.4 %) 114 (71.7 %) 181 (67.0 %)
 Other 2 (1.8 %) 6 (3.8 %) 8 (3.0 %)
Sexual orientation 0.230
 Straight or heterosexual 10 (9.0 %) 11 (6.9 %) 21 (7.8 %)
 Lesbian 9 (8.1 %) 23 (14.5 %) 32 (11.9 %)
 Gay 11 (9.9 %) 10 (6.3 %) 21 (7.8 %)
 Bisexual 24 (21.6 %) 43 (27.0 %) 67 (24.8 %)
 Queer 23 (20.7 %) 35 (22.0 %) 58 (21.5 %)
 Pansexual 19 (17.1 %) 24 (15.1 %) 43 (15.9 %)
 Same-gender loving 2 (1.8 %) 1 (0.6 %) 3 (1.1 %)
 Asexual 13 (11.7 %) 9 (5.7 %) 22 (8.1 %)
 Other 0 (0.0 %) 3 (1.9 %) 3 (1.1 %)
Education level 0.739
 High school and below 40 (25.2 %) 33 (29.7 %) 73 (27.0 %)
 Some college 56 (35.2 %) 34 (30.6 %) 90 (33.3 %)
 Associate degree 22 (13.8 %) 13 (11.7 %) 35 (13.0 %)
 College and above 41 (25.8 %) 31 (27.9 %) 72 (26.7 %)
Race/ethnicity 0.610
 White 55 (34.6 %) 33 (29.7 %) 88 (32.6 %)
 Black/African American 17 (10.7 %) 13 (11.7 %) 30 (11.1 %)
 Hispanic/Latin/Spanish origin 44 (27.7 %) 34 (30.6 %) 78 (28.9 %)
 Asian 34 (21.4 %) 20 (18.0 %) 54 (20.0 %)
 Others 9 (5.7 %) 11 (9.9 %) 20 (7.4 %)
Relationship Status 0.643
 Single 107 (67.3 %) 71 (64.0 %) 178 (65.9 %)
 Married 9 (5.7 %) 6 (5.4 %) 15 (5.6 %)
 Living with a partner 35 (22.0 %) 24 (21.6 %) 59 (21.9 %)
 Others 8 (5.0 %) 10 (9.0 %) 18 (6.7 %)
Income level 0.056
 Under $12,000 70 (44.0 %) 62 (55.9 %) 132 (48.9 %)
 $12,000 and above 89 (56.0 %) 49 (44.1 %) 138 (51.1 %)
Housing status 0.049
 Housing stable 139 (87.4 %) 105 (94.6 %) 244 (90.4 %)
 Housing instable 20 (12.6 %) 6 (5.4 %) 26 (9.6 %)
Nicotine dependence 15 (9.4 %) 8 (7.2 %) 23 (8.5 %) 0.519
Internalized transphobia 2.822 (0.843) 2.577 (0.904) 2.721 (0.876) 0.023
Gender identity disclosure 2.538 (0.876) 2.905 (0.898) 2.689 (0.902) < 0.001
Multilevel social support 4.602 (1.204) 5.030 (1.289) 4.778 (1.255) 0.006
Psychological distress (K6≥13) 159 (58.9 %)
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K6 = Kessler.

Bold texts indicate statistically significant.

2.3. Data analysis

We first used descriptive statistics to summarize participant’s characteristics, including percentage, mean, standard deviation, median, etc. Next, we conducted bivariable logistic regressions to examine the bivariate association between sociodemographic characteristics and psychological distress. Next, correlation coefficients were calculated to describe the associations between internalized transphobia, gender identity disclosure, social support, and psychological distress. Next, we examined the indirect effects of social support and gender identity disclosure on the relationship between internalized transphobia and psychological distress, exploring how these factors indirectly influence the link between internalized transphobia and psychological distress. Both models adjusted for differences in psychological distress detected in the bivariable logistic regression. A p-value less than 0.05 was considered statistically significant and all analyses were conducted using RStudio and STATA. For the indirect effect analyses, we used the lavaan package in R (Rosseel, 2012).

3. Results

3.1. Participants characteristics

A total of n = 270 TGNC participants were included in the current analysis. The average age was 22.9 years old (standard deviation: 3.1), and 73 % of the participants had some college degree. The participants were racially and ethnically diverse, with 32.6 % self-identified as White, 28.9 % and 20 % were Hispanic/Latin/Spanish origin and Asian, and 11.1 % were identified as Black/African American. In terms of participant’s gender identity and sexual orientation, two thirds (67.0 %) were identified as gender non-confirming, and 16.3 % and 13.7 % were identified transgender male/man and transgender female/woman, respectively. A majority of participants were single (65.9 %) and nearly half had an annual income below $12,000. Nearly one in ten (9.6 %) reported housing instability. Based on the Penn State Nicotine Dependence Index, 8.5 % of the participants screened positive for nicotine dependence. According to the K6, 58.9 % of the TGNC participants screened positive for psychological distress. A complete description of participant’s characteristics was presented in Table 1.

3.2. Associations between main study variables

The correlation matrix (Table 2) presented the associations between main study variables. Internalized transphobia was negatively associated with gender identity disclosure and social support (r = −0.49 and r = −0.22, p < 0.011, respectively), and positively associated with experiencing psychological distress (r = 0.14, p < 0.05). Meanwhile, gender identity disclosure and social support were positively correlated (r = 0.12, p < 0.05), and they were both negatively correlated with psychological distress (r = −0.20, r = −0.17, p < 0.01, respectively).

Table 2.

Descriptive statistics and correlation matrix of main study measures.

1 2 3 4 Mean (SD) Range Skewness Kurtosis
1 Internalized transphobia – 2.7 (0.9) 1–4 0.14 −0.33
2 Gender identity disclosure −0.49b – 2.7 (0.9) 1–3 −0.10 −1.10
3 Social support −0.22b 0.12a – 4.8 (1.3) 1–6 −0.50 −0.04
4 Psychological distress 0.14a −0.20** −0.17a – 13.5 (5.8) 0–24 −0.11 −0.39
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SD: standard deviation.

a

p < 0.05.

b

p < 0.01.

3.3. Indirect effects of social support and gender identity disclosure

Fig. 1 presents the results of the path analyses. In the initial bivariate model, internalized transphobia was positively associated with psychological distress (b = 0.07, p = 0.02). The first model tested the proposed role of social support (M) in the relationship between internalized transphobia (IV) and psychological distress (DV), while adjusting for housing status. Internalized transphobia (IV) was significantly associated with lower levels of social support (M) (b = −0.316, p < 0.001), and social support (M) was significantly associated with lower psychological distress (DV) (b = −0.057, p < 0.01). The direct effect of internalized transphobia (IV) on psychological distress (DV) became non-significant (b = 0.06, p = 0.08). Approximately 23 % of the effect of internalized transphobia on psychological distress were indirectly affected by perceived social support. Similarly, gender identity disclosure (M) indirectly affected the relationship between internalized transphobia (IV) and psychological distress (DV), accounting for 62 % of the total effect.

Fig. 1.

Fig. 1.

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Indirect effects of social support and gender identity disclosure on the relationship between internalized transphobia and psychological distress.

4. Discussion

This study contributes to growing literature on underlying mechanisms that link proximal stressors to adverse mental wellbeing by examining the roles of social support and gender identity nondisclosure in the relationship between internalized transphobia and psychological distress. Consistent with our first hypothesis, our analyses found that higher levels of internalized transphobia were associated with greater psychological distress among TGNC participants. This finding aligned with previous research showing a correlation between internalized transphobia and various adverse mental health outcomes, such as psychological distress, depression, anxiety, post-traumatic stress disorder, suicidality, and general mental wellbeing (Barr et al., 2022; Conn et al., 2023; Garro et al., 2022; Graziano et al., 2024; Lee et al., 2020; Mann et al., 2023; Perez-Brumer et al., 2015; Tebbe and Moradi, 2016). Indeed, internalized transphobia may be especially detrimental for mental wellbeing of TGNC persons considering it is the most proximal for the person experiencing the stressor and can challenge the person’s ability to develop adaptive coping mechanisms and resilience (Hendricks and Testa, 2012; Lloyd et al., 2019).

We also found that higher levels of perceived social support and gender identity disclosure were associated with lower levels of psychological distress. The role of social support in favorable mental health outcomes is consistent with both theoretical and empirical research pointing to the potentially stress ameliorating role that social support can play in the lives of TGNC persons (Kaplan et al., 2019; Pflum et al., 2015; Trujillo et al., 2017). Although the evidence was less consistent, several studies examining the impact of sexual and gender identity disclosure on mental wellbeing also suggest benefits of disclosure (Gnan et al., 2019; Pachankis et al., 2020; Pellicane and Ciesla, 2022), while some failed to find similar benefits (Graziano et al., 2024; Helsen et al., 2022; Jones et al., 2022; Osmetti et al., 2024). These differing findings may be related to varying conceptualization of gender identity disclosure or lack thereof, which is sometimes used interchangeably with the concept of concealment (Osmetti et al., 2024). Previous literature suggests there may be a nuanced relationship between disclosure decisions and mental wellbeing, influenced by the protective role of non-disclosure against distal stressors (e.g., discrimination) and resulting mental health challenges, while also being an additional source of stress for those who choose not to disclosure their gender identity (Bränström and Pachankis, 2021; Owens et al., 2023; Pellicane and Ciesla, 2022). Further work is critical in better elucidating the complex role of gender identity disclosure in mental health among this population.

Our results also support the second and third hypotheses regarding the indirect effects of social support and gender identity disclosure in the relationship between internalized transphobia and psychological distress. Social support and gender identity disclosure have an indirect effect on the aforementioned association, highlighting the potential importance of these two factors as mechanisms that should be considered to improve psychological distress among TGNC persons. Alongside its protective role against distal stressors, social support has been identified in previous studies as a key factor in mitigating the impact of internalized transphobia on mental wellbeing among TGNC persons (Garro et al., 2022; Mann et al., 2023; Scandurra et al., 2018). Our findings add further evidence for the importance of fostering a supportive social environment to enhance the mental wellbeing of TGNC persons. Meanwhile, internalized transphobia may also be influenced by a propensity for social desirability (Bockting et al., 2020), where TGNC persons who are alienated from supportive social systems may internalize stigmatizing beliefs about their gender identities in order to achieve greater social desirability in unsupportive environments. It is plausible that a lack of access to affirming social support systems and internalized transphobia are mutually reinforcing, ultimately leading to increased psychological distress (Hatzenbuehler, 2009; Mann et al., 2023; Owens et al., 2023). A possible explanation for the findings in this study is that TGNC youth experiencing stigmatization and resultant internalized stigma may disengage from others to avoid further stigmatization (Ehlke et al., 2020; Hatzenbuehler, 2009; Owens et al., 2023; Pellicane and Ciesla, 2022). If the TGNC identity and associated stigma is concealed, avoidance of social interactions may also serve to protect one from potential exposure (Pachankis, 2007). Ensuing lack of support can then negatively influence one’s distress.

The role of gender identity disclosure is similarly complex; as described above, internalized transphobia is linked to anticipation of future stigmatization (Owens et al., 2023; Pellicane and Ciesla, 2022), which could lead to nondisclosure of one’s gender identity and ultimately poorer mental wellbeing. Lloyd et al. (2019) suggested that internalized negative beliefs resulting from distal stress experiences may precipitate TGNC persons to attempt regulation of their physical and mental wellbeing through maladaptive means, such as avoidance of potentially stigmatizing situations (Lloyd et al., 2019). A decision against disclosure may represent a form of avoidance aimed at preventing future stigmatization. Cumulatively, the emotional toll of these stressful internal processes can contribute to poorer mental wellbeing including psychological distress in addition to hampering efforts to reach out for social support (Lloyd et al., 2019). It is also important to note that social support and gender identity disclosure explained 23 % and 62 % of the impact of internalized transphobia on psychological distress, respectively, indicating the need to understand additional factors beyond social support and gender identity disclosure to better support the mental wellbeing of TGNC persons.

4.1. Limitations

A discussion of certain limitations is critical to appropriately contextualize our study findings. Due to the cross-sectional nature of the data, we are limited in our ability to make causal inferences from our findings. Similarly, the TRDRP dataset only includes TGNC individuals between the ages of 18–29 residing in California who used tobacco products; This limits the generalizability of the study findings to TGNC minors or adults over the age of 29 as well as TGNC persons living outside California. TGNC adults over the age of 29 may have different developmental and generational experiences, including earlier exposure to more hostile social climates, distinct trajectories of gender identity development, and different patterns of social support or psychological distress. Moreover, structural stigma varies significantly by location; California generally offers a more affirming legal and healthcare environment for TGNC individuals, which may shape both access to social support and experiences of internalized transphobia. TGNC persons living in states or regions with fewer protections or greater discrimination may experience different relationships between these variables. Furthermore, our exclusive inclusion of tobacco users may bias the sample toward individuals experiencing higher levels of psychological distress, given the established link between tobacco use and mental health symptoms (Taylor et al., 2014). Substance use among TGNC individuals is often described as a coping mechanism against stigmatizing experiences and other life stressors (Cotaina et al., 2022; Felner et al., 2020). Additionally, all study outcomes relied on self-reported measures, which may be subject to social desirability bias or recall bias, potentially affecting the accuracy of the data. As a secondary analysis, we were limited to the measures and constructs originally collected in the parent study, which may not have fully captured the theoretical dimensions or variables most relevant to our research questions. For example, future studies on transphobia should utilize more established scales such as the Transgender Identity Survey (Bockting et al., 2020) to measure the multidimensional aspects of internalized transphobia. Finally, while we chose to dichotomize the K6 scale to identify participants experiencing clinically significant psychological distress, we acknowledge that this approach may reduce statistical power and obscure important variation in symptom severity. Our decision was guided by precedent in the literature and public health practice: the K6 was originally validated with a recommended cutoff score (Kessler et al., 2003), which has since been widely adopted in population-based research and surveillance. Dichotomization also aligns with the objectives of the parent study, which aimed to characterize disparities in clinically significant distress among sexual and gender minority young adults. This analytic choice facilitates comparability with existing literature and supports the translational goal of informing policy, programming, and service provision for TGNC populations.

5. Conclusion

Our findings add further evidence linking internalized transphobia to higher psychological distress among a sample of young TGNC adults living in California. Our findings additionally elucidate the critical roles of social support and disclosure of gender identity in this relationship. While identification of these underlying mechanisms is critical for informing points for intervention aimed at improving mental wellbeing among TGNC persons, additional research is needed to better describe the roles of social support and gender identity disclosure.

Acknowledgement:

The authors thank all of the community members who participated in this study.

Funding

This project was supported in part by award number 28IP-0032 from the California Tobacco-Related Disease Research Program (TRDRP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funder.

Footnotes

CRediT authorship contribution statement

Chenglin Hong: Writing – original draft, Methodology, Investigation, Formal analysis, Data curation. Tural Mammadli: Writing – original draft. Elizabeth S.C. Wu: Writing – original draft, Project administration. Ian W. Holloway: Writing – original draft, Project administration, Funding acquisition.

Declaration of competing interest

All authors declare no conflict of interest.

References

  1. Azam S, Ayub S, 2023. Self-objectification, internalized transphobia and psychological distress in male-to-female transgenders. Journal of Professional & Applied Psychology 4 (2), 2. 10.52053/jpap.v4i2.168. [DOI] [Google Scholar]
  2. Barr SM, Snyder KE, Adelson JL, Budge SL, 2022. Posttraumatic stress in the trans community: the roles of anti-transgender bias, non-affirmation, and internalized transphobia. Psychol. Sexual Orientation Gender Diversity 9 (4), 410–421. 10.1037/sgd0000500. [DOI] [Google Scholar]
  3. Bazzi AR, Yotebieng KA, Agot K, Rota G, Syvertsen JL, 2018. Perspectives on biomedical HIV prevention options among women who inject drugs in Kenya. AIDS Care 30 (3), 343–346. 10.1080/09540121.2017.1363369. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Becerra MB, Rodriquez EJ, Avina RM, Becerra BJ, 2021. Experiences of violence and mental health outcomes among Asian American transgender adults in the United States. PLoS One 16 (3), e0247812. 10.1371/journal.pone.0247812. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bockting WO, Miner MH, Swinburne Romine RE, Dolezal C, Robinson BBE, Rosser BRS, Coleman E, 2020. The transgender identity survey: a measure of Internalized transphobia. LGBT Health 7 (1), 15–27. 10.1089/lgbt.2018.0265. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E, 2013. Stigma, mental health, and resilience in an online sample of the US transgender population. Am. J. Publ. Health 103 (5), 943–951. 10.2105/AJPH.2013.301241. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Bränström R, Pachankis JE, 2021. Country-level structural stigma, identity concealment, and day-to-day discrimination as determinants of transgender people’s life satisfaction. Soc. Psychiatr. Psychiatr. Epidemiol 56 (9), 1537–1545. 10.1007/s00127-021-02036-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Brooks VR, 1981. Minority Stress and Lesbian Women. Lexington Books. [Google Scholar]
  9. Conn BM, Chen D, Olson-Kennedy J, Chan Y-M, Ehrensaft D, Garofalo R, Rosenthal SM, Tishelman A, Hidalgo MA, 2023. High internalized transphobia and low gender identity pride are associated with depression symptoms among transgender and gender-diverse youth. J. Adolesc. Health: Official Publication of the Society for Adolescent Medicine 72 (6), 877–884. 10.1016/j.jadohealth.2023.02.036. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cotaina M, Peraire M, Boscá M, Echeverria I, Benito A, Haro G, 2022. Substance use in the transgender population: a meta-analysis. Brain Sci. 12 (3), 366. 10.3390/brainsci12030366. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Crissman HP, Stroumsa D, Kobernik EK, Berger MB, 2019. Gender and frequent mental distress: comparing transgender and non-transgender individuals’ self-rated mental health. J. Wom. Health 28 (2), 143–151. 10.1089/jwh.2018.7411, 2002. [DOI] [PubMed] [Google Scholar]
  12. Ehlke SJ, Braitman AL, Dawson CA, Heron KE, Lewis RJ, 2020. Sexual minority stress and social support explain the association between sexual identity with physical and mental health problems among young lesbian and bisexual women. Sex. Roles 83 (5–6), 370–381. 10.1007/s11199-019-01117-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Felner JK, Wisdom JP, Williams T, Katuska L, Haley SJ, Jun H-J, Corliss HL, 2020. Stress, coping, and context: examining substance use among LGBTQ young adults with probable substance use disorders. Psychiatr. Serv 71 (2), 112–120. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Fuller KA, Riggs DW, 2018. Family support and discrimination and their relationship to psychological distress and resilience amongst transgender people. Int. J. Transgenderism 19 (4), 379–388. 10.1080/15532739.2018.1500966. [DOI] [Google Scholar]
  15. Garro M, Novara C, Di Napoli G, Scandurra C, Bochicchio V, Lavanco G, 2022. The role of internalized transphobia, loneliness, and social support in the psychological well-being of a group of Italian transgender and gender non-conforming youths. Healthcare (Basel, Switzerland) 10 (11), 2282. 10.3390/healthcare10112282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Gnan GH, Rahman Q, Ussher G, Baker D, West E, Rimes KA, 2019. General and LGBTQ-Specific factors associated with mental health and suicide risk among LGBTQ students. J. Youth Stud 22 (10), 1393–1408. 10.1080/13676261.2019.1581361. [DOI] [Google Scholar]
  17. Graziano TA, Fitzgerald HN, Ortiz J, Owen CK, Shook NJ, 2024. Internalized phobia, community connectedness, outness, and mental health risk and protection in LGBTQ persons. Nurs. Res 10.1097/NNR.0000000000000759. [DOI] [PubMed] [Google Scholar]
  18. Hatzenbuehler ML, 2009. How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol. Bull 135 (5), 707–730. 10.1037/a0016441. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Helsen V, Enzlin P, Gijs L, 2022. Mental health in transgender adults: the role of proximal minority stress, community connectedness, and gender nonconformity. Psychol. Sexual Orientation Gender Diversity 9 (4), 466–477. 10.1037/sgd0000530. [DOI] [Google Scholar]
  20. Hendricks ML, Testa RJ, 2012. A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the minority stress model. Prof. Psychol. Res. Pract 43 (5), 460–467. 10.1037/a0029597. [DOI] [Google Scholar]
  21. Hong C, Hoskin J, Berteau LK, Schamel JT, Wu ESC, King AR, Randall LA, Holloway IW, Frew PM, 2023a. Violence victimization, homelessness, and severe mental illness among people who use opioids in three U.S. cities. J. Interpers Violence 38 (19–20), 11165–11185. 10.1177/08862605231179720. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Hong C, Ochoa AM, Wilson BDM, Wu ESC, Thomas D, Holloway IW, 2023b. The associations between HIV stigma and mental health symptoms, life satisfaction, and quality of life among black sexual minority men with HIV. Qual. Life Res 32 (6), 1693–1702. 10.1007/s11136-023-03342-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Inderbinen M, Schaefer K, Schneeberger A, Gaab J, Garcia Nuñez D, 2021. Relationship of internalized transnegativity and protective factors with depression, anxiety, non-suicidal self-injury and suicidal tendency in trans populations: a systematic review. Front. Psychiatr 12. 10.3389/fpsyt.2021.636513. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Jones AK, Wehner CL, Andrade IM, Jones EM, Wooten LH, Wilson LC, 2022. Minority stress and posttraumatic growth in the transgender and nonbinary community. Psychology of Sexual Orientation and Gender Diversity, No Pagination Specified-No Pagination Specified. 10.1037/sgd0000610. [DOI] [Google Scholar]
  25. Kaplan SC, Butler RM, Devlin EA, Testa RJ, Horenstein A, Swee MB, Heimberg RG, 2019. Rural living environment predicts social anxiety in transgender and gender nonconforming individuals across Canada and the United States. J. Anxiety Disord 66, 102116. 10.1016/j.janxdis.2019.102116. [DOI] [PubMed] [Google Scholar]
  26. Kerr DCR, Bae H, Dermody SS, 2024. Trends and disparities in suicidal thoughts and behaviors and mental health symptoms among sexual and gender minority college students in the U.S., 2008–2018. Psychol. Sexual Orientation Gender Diversity 11 (2), 305–315. 10.1037/sgd0000599. [DOI] [Google Scholar]
  27. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand S-L, Walters EE, Zaslavsky AM, 2002. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol. Med 32 (6), 959–976. [DOI] [PubMed] [Google Scholar]
  28. Krueger EA, Hong C, Cunningham NJ, Berteau L. (Katy), Cordero L, Wu ESC, Holloway IW, 2023. Prevalence of nicotine and tobacco product use by sexual identity, gender identity, and sex assigned at birth among emerging adult tobacco users in California, United States. Nicotine Tob. Res 25 (7), 1378–1385. 10.1093/ntr/ntad048. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Lee H, Tomita KK, Habarth JM, Operario D, Yi H, Choo S, Kim S-S, 2020. Internalized transphobia and mental health among transgender adults: a nationwide cross-sectional survey in South Korea. Int. J. Transgender Health 21 (2), 182–193. 10.1080/26895269.2020.1745113. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Lefevor GT, Sprague BM, Boyd-Rogers CC, Smack ACP, 2019. How well do various types of support buffer psychological distress among transgender and gender nonconforming students? Int. J. Transgenderism 20 (1), 39–48. 10.1080/15532739.2018.1452172. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Lloyd J, Chalklin V, Bond FW, 2019. Psychological processes underlying the impact of gender-related discrimination on psychological distress in transgender and gender nonconforming people. J. Counsel. Psychol 66 (5), 550–563. 10.1037/cou0000371. [DOI] [PubMed] [Google Scholar]
  32. London-Nadeau K, Chadi N, Taylor AB, Chan A, Pullen Sansfaçon A, Chiniara L, Lefebvre C, Saewyc EM, 2023. Social support and mental health among transgender and nonbinary youth in Quebec. LGBT Health 10 (4), 306–314. 10.1089/lgbt.2022.0156. [DOI] [PubMed] [Google Scholar]
  33. Mann AK, Fredrick EG, Wilkins BT, 2023. Growing up in a rural area, social support, and internalized transphobia: understanding Appalachian transgender mental and physical health. Stigma and Health. 10.1037/sah0000425. No Pagination Specified-No Pagination Specified. [DOI] [Google Scholar]
  34. McDowell MJ, Hughto JMW, Reisner SL, 2019. Risk and protective factors for mental health morbidity in a community sample of female-to-male trans-masculine adults. BMC Psychiatry 19 (1), 16. 10.1186/s12888-018-2008-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Moradi B, Parent MC, Nusrath SF, Falk MR, 2023. Citation network analysis of minority stress scholarship: past, present, and potential directions. Psychol. Sexual Orientation Gender Diversity 10.1037/sgd0000670. [DOI] [Google Scholar]
  36. Meyer IH, 2003. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol. Bull 129 (5), 674–697. 10.1037/0033-2909.129.5.674. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Meyer IH, Rossano L, Ellis JM, Bradford J, 2002. A brief telephone interview to identify lesbian and bisexual women in random digit dialing sampling. J. Sex. Res 39 (2), 139–144. [DOI] [PubMed] [Google Scholar]
  38. Osmetti LA, Allen KR, Kozlowski D, 2024. Shortcomings of transgender identity concealment research: a scoping review of associations with mental health. Int. J. Transgender Health 0 (0), 1–25. 10.1080/26895269.2024.2367653. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Oswalt SB, Lederer AM, 2017. Beyond depression and suicide: the mental health of transgender college students. Soc. Sci 6 (1), 1. 10.3390/socsci6010020. [DOI] [Google Scholar]
  40. Owens TK, Mizock L, Ormerod AJ, Nelson A, St Amand C, Paces-Wiles D, Judd TD, 2023. “invisible in the Most tragic of ways”: exploring internalized transphobia and coping through photovoice. Health Promot. Pract 24 (4), 682–693. 10.1177/15248399221114340. [DOI] [PubMed] [Google Scholar]
  41. Pachankis JE, 2007. The psychological implications of concealing a stigma: a cognitive-affective-behavioral model. Psychol. Bull 133 (2), 328–345. 10.1037/0033-2909.133.2.328. [DOI] [PubMed] [Google Scholar]
  42. Pachankis JE, Mahon CP, Jackson SD, Fetzner BK, Bränström R, 2020. Sexual orientation concealment and mental health: a conceptual and meta-analytic review. Psychol. Bull 146 (10), 831–871. 10.1037/bul0000271. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Pellicane MJ, Ciesla JA, 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. 10.1016/j.cpr.2021.102113. [DOI] [PubMed] [Google Scholar]
  44. Perez-Brumer A, Hatzenbuehler ML, Oldenburg CE, Bockting W, 2015. Individual- and structural-level risk factors for suicide attempts among transgender adults. Behav. Med 41 (3), 164–171. 10.1080/08964289.2015.1028322. Washington, D.C. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Pflum SR, Testa RJ, Balsam KF, Goldblum PB, Bongar B, 2015. Social support, trans community connectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychol. Sexual Orientation Gender Diversity 2 (3), 281–286. 10.1037/sgd0000122. [DOI] [Google Scholar]
  46. Puckett JA, Matsuno E, Dyar C, Mustanski B, Newcomb ME, 2019. Mental health and resilience in transgender individuals: what type of support makes a difference? J. Fam. Psychol.: JFP: Journal of the Division of Family Psychology of the American Psychological Association (Division 43) 33 (8), 954–964. 10.1037/fam0000561. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Robertson L, Akŕe E-R, Gonzales G, 2021. Mental health disparities at the intersections of gender identity, race, and ethnicity. LGBT Health 8 (8), 526–535. 10.1089/lgbt.2020.0429. [DOI] [PubMed] [Google Scholar]
  48. Rood BA, Reisner SL, Puckett JA, Surace FI, Berman AK, Pantalone DW, 2017. Internalized transphobia: exploring perceptions of social messages in transgender and gender-nonconforming adults. Int. J. Transgenderism 18 (4), 411–426. 10.1080/15532739.2017.1329048. [DOI] [Google Scholar]
  49. Rosseel Y, 2012. Lavaan: an R package for structural equation modeling. J. Stat. Software 48, 1–36. 10.18637/jss.v048.i02. [DOI] [Google Scholar]
  50. Scandurra C, Bochicchio V, Amodeo AL, Esposito C, Valerio P, Maldonato NM, Bacchini D, Vitelli R, 2018. Internalized transphobia, resilience, and mental health: applying the psychological mediation framework to Italian transgender individuals. Int. J. Environ. Res. Publ. Health 15 (3), 508. 10.3390/ijerph15030508. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Tebbe EA, Moradi B, 2016. Suicide risk in trans populations: an application of minority stress theory. J. Counsel. Psychol 63 (5), 520–533. 10.1037/cou0000152. [DOI] [PubMed] [Google Scholar]
  52. Testa RJ, Habarth J, Peta J, Balsam K, Bockting W, 2015. Development of the gender minority stress and resilience measure. Psychol. Sexual Orientation Gender Diversity 2 (1), 65–77. 10.1037/sgd0000081. [DOI] [Google Scholar]
  53. Timmins L, Rimes KA, Rahman Q, 2017. Minority stressors and psychological distress in transgender individuals. Psychol. Sexual Orientation Gender Diversity 4 (3), 328–340. 10.1037/sgd0000237. [DOI] [Google Scholar]
  54. Trujillo MA, Perrin PB, Sutter M, Tabaac A, Benotsch EG, 2017. The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. Int. J. Transgenderism 18 (1), 39–52. 10.1080/15532739.2016.1247405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Wilson EC, Chen Y-H, Arayasirikul S, Raymond HF, McFarland W, 2016. The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support. AIDS Behav. 20 (10), 2203–2211. 10.1007/s10461-016-1409-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Zimet GD, Dahlem NW, Zimet SG, Farley GK, 1988. The multidimensional scale of perceived social support. J. Pers. Assess 52 (1), 30–41. 10.1207/s15327752jpa5201_2. [DOI] [PubMed] [Google Scholar]

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