Determinants of Transgender Individuals’ Well-Being, Mental Health, and Suicidality in a Rural State

Abstract

This project utilized a Community-Based Participatory Research (CBPR) approach to conduct qualitative interviews with 30 transgender adults living in a rural state. Participants’ identities spanned from trans women and men to non-binary and Two-Spirit. The aim of this study was to better understand the experiences, needs, and priorities of the participants as well as to examine possible determinants of mental health, well-being, and suicidality for transgender individuals in Montana. These factors were investigated at individual, interpersonal, community, and societal levels using an ecological framework. Qualitative results indicate that participants experienced discrimination at all levels. Participants noted that discrimination contributed to mental health challenges and limited access to adequate general and transgender-specific healthcare services, both of which impacted overall well-being. This is reflected most notably in the elevated rate of past suicidal ideation attempts among the sample. Participants reported that the ability to transition, as well as other protective factors, played a role in reducing suicidality and improving mental and physical health. Our findings highlight the need to address transgender mental health through implementing changes at multiple ecological levels.

Transgender is an umbrella term for persons who do not conform to gender norms associated with the sex to which they were assigned at birth. Transgender persons’ experiences of social stigma, such as isolation, marginalization, lack of social support, discrimination, and violence have been linked with depression, anxiety, and suicidality (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Budge, Adelson, & Howard, 2013; Clements-Nolle, Marx, Guzman, & Katz, 2001; Clements-Nolle, Marx, & Katz, 2006; Hendricks & Testa, 2012; Mizock & Mueser, 2014; Nadal, Davidoff, Davis, & Wong, 2014; Nuttbrock et al., 2012). The National Transgender Discrimination Study (N = 27,715) reported transgender persons were three times more likely to be unemployed than the general population (James et al., 2016). This same study found 40% of participants had attempted suicide. The Institute of Medicine (2011) issued a report entitled The Health of Lesbian, Gay, Bisexual, and Transgender People that found high rates of substance abuse and suicide attempts, as well as HIV infection and other health disparities in transgender adults and concluded that transphobia and marginalization have substantial adverse effects on the physical and mental health of transgender people.

In addition to social stigma more broadly, research indicates that transgender persons experience discrimination, stigma, and/or insensitivity from healthcare providers, which impacts their health care access and utilization and serves to perpetuate health disparities (Bauer, Scheim, Deutsch, & Massarella, 2014; Grant et al., 2011; Poteat, German, & Kerrigan, 2013; Sanchez, Sanchez, & Danoff, 2009; Sperber, Landers, & Lawrence, 2005; Xavier et al., 2013). The probability of discrimination in a medical setting increased if providers were aware of a patient’s transgender status (Grant et al., 2011). This discrimination may be the result of medical providers’ beliefs about lesbian, gay, bisexual, and transgender (LGBT) persons, which, in turn, can impact treatment quality (Chapman, Watkins, Zappia, Nicol, & Shields, 2011).

Experiences like these of marginalization, discrimination, and stigmatization can lead to mental health problems, disruption of general well-being, and suicidality, as described by the concept of minority stress (Meyer, 2003). Minority stress, as applied to transgender persons, suggests that stigma, prejudice, and discrimination create a hostile social environment, which leads to internalized transphobia and disturbances in mental health, including depression, anxiety, post-traumatic stress, and suicidality (Gamarel, Laurenceau, Reisner, Nemoto, & Operario, 2014; Hendricks & Testa, 2012; Testa et al., 2012). In support of this model, one study found that transgender youth who had “strong parental support for their gender identity and expression reported higher life-satisfaction, higher self-esteem, better mental health including less depression and fewer suicide attempts, and adequate housing compared to those without strong parental support” (Travers et al., 2012, p. 2). Another study found that suicide risk decreased when transgender persons had completed desired medical transitions (e.g., hormones, surgeries), had social support, experienced decreased transphobia, and had personal identification documents changed to reflect their true gender (Bauer, Scheim, Pyne, Travers, & Hammond, 2015). These studies suggest that when transgender persons receive both emotional support and support for their needs, they appear to have increased well-being and mental health, as well as decreased suicidality.

Little is known about transgender persons living in rural areas, including their experiences, needs, and priorities. In rural states and communities, the challenges vary from those that transgender persons face in urban areas (Koch & Knutson, 2016; Snively, 2004). Small rural communities often do not have the political, religious, social, ideological, economic, or cultural diversity of urban populations (Hastings & Hoover-Thompson, 2011). Because traditional values are typical in rural areas, those who have variant gender identities or presentations may feel unwelcome (Boulden, 2001). Healthcare service limitations, such as lack of confidentiality, stigma, and a lack of mental health and medical providers qualified to work with transgender persons, exacerbate rural transgender persons’ psychological distress (Willging, Salvador, & Kano, 2006). Although personal and family pride and community belonging may serve as buffers against suicidality for rural individuals (Hirsch & Cukrowicz, 2014), transgender persons consistently experience marginalization, isolation, and deficits in family and social support (Budge, Katz-Wise, et al., 2013; Koken, Bimbi, & Parsons, 2009; Nemoto, Bödeker, & Iwamoto, 2011; Rhodes et al., 2015). Thus, protective factors for rural transgender persons may be limited.

Small rural communities are not monolithic and may contain individuals with important intersecting identities. In Montana, the largest ethnic minority group is Native American individuals, who represent 6.6% of the state’s population (as compared to 2% of the general U.S. population; U.S.Census Bureau, 2014). Many tribes across the United States have historically recognized non-binary (i.e., beyond male and female) gender identities, and there have been many reports of these identities encompassed under the term “Two-Spirit” (Lang, 2016). How these identities are articulated varies tremendously across individual tribes in terms of social traditions and gender roles. Researchers focusing on LGBT populations have increasingly begun to study complex identities espoused by individuals, such as “Two-Spirit” Native Americans, for whom ethnicity, socioeconomic status, and ability status may intersect to result in unique lived experiences for transgender people with multiple minority statuses (e.g., Ginicola, 2017).

The Current Study

Montana has a total population estimate of 1,042,520 (U.S. Census, 2016). Using a definition of transgender as individuals whose gender identity and/or expression is different from their assigned sex at birth, we estimate that approximately 3,000 (0.3%) transgender individuals reside in this predominately rural state (Conron, Scott, Stowell, & Landers, 2012; Conway, 2002; Los Angeles County Department of Public Health, Division of HIV and STD Programs, 2012; Gates, 2011; Scheim & Bauer, 2014; US Census Bureau, 2014). By transcending cultural gender norms, transgender persons living in Montana demonstrate strength and resiliency in the face of adversity. However, a significant proportion of this population experiences psychological distress, and it has been estimated that over 50% of transgender persons in Montana have experienced suicidality (Sutherland & Bourke, 2013). In Montana, although several localities have instituted nondiscrimination ordinances (NDOs), which are transgender inclusive and offer protections in the areas of housing, employment, and public accommodations, there are no such protections at the state level for LGBT persons regarding discrimination and basic human rights (Transgender Law Center, 2017).

Little research has been conducted to understand the factors influencing the mental health, well-being, and suicidality of transgender persons living in rural areas such as Montana. Developing an understanding of these factors will enable the implementation of interventions to reduce risk of psychological distress and strengthen support for mental health. In the current study, we used a qualitative Community-Based Participatory Research (CBPR) approach to identify the determinants of rural transgender mental health and suicidality.

Method

This project utilized a CBPR approach to conduct qualitative interviews with 30 transgender adults living in a rural state with the aim of identifying determinants of rural transgender mental health and suicidality. The CBPR approach provided a guide for the entire research process from inception to collection, analysis, and presentation of data. Such an approach is community-driven and culturally consonant with working with vulnerable populations on mental health topics (Duran & Wallerstein, 2003). An emphasis is placed on forming an equitable partnership between community members and researchers in which all partners share decision-making and ownership of the research process (Israel, Schulz, Parker, & Becker, 1998).

Formation of a Community Advisory Board (CAB)

The third author, who is the Project Coordinator, initiated the formation of a Community Advisory Board (CAB). The CAB, comprised of four transgender persons and one transgender ally, met monthly from February 2014 through May 2017. CABs have been recognized as an essential element of a CBPR approach (Duran & Wallerstein, 2003). Research suggests that studies developed in partnership with community members are more likely to be endorsed by the community (Rhodes, Song, Namb, Choi, & Choi, 2015). The utilization of the CAB also helped to address the potential of researcher bias throughout data collection and analysis. As both the first and second author do not identify as transgender and therefore occupy an “outsider” perspective in the context of this research (Dwyer & Buckle, 2009), the CAB ensured the involvement of transgender community members throughout research design and analysis, helping to mitigate the potential of outsider bias in influencing key research findings. In this spirit, our CAB has guided decisions at each stage of the research, including project design and implementation, participant recruitment, and data analysis and interpretation.

The Partners (Project Coordinator, CAB, Principal Investigator) also formed close, working partnerships with community organizations. Consultants and experts who were either not from Montana or not a part of the transgender community were engaged to assist on developing interview questions, qualitative analysis, and project development.

Ecological Framework

The Partners designed a semi-structured interview guide that was used to conduct interviews with transgender individuals throughout Montana. The guide was based on Northridge, McGrath, and Krueger’s (2007) ecological framework of LGBT health, modified to include factors that impact suicidality in rural areas. The framework’s first level focuses on factors that impact health outcomes and the well-being of individuals. The second level emphasizes interpersonal dynamics, such as stressors/buffers, health behaviors, personal relationships, and social integration. The third level addresses community factors including the built environment and social context. The fourth level focuses on societal factors such as natural environment, macrosocial factors, and inequalities.

Thus, the interview guide was designed to gather in-depth qualitative (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999) data at each of the four levels. The guide was developed iteratively by the Partners through an ongoing review of the literature; brainstorming of domains and constructs; and development, review, and revision of potential questions. The interview guide included 13 groups of qualitative questions that addressed the four levels of our framework: Demographics, Gender Identity, Social Network/Community, Discrimination, Employment, Sexuality, Legal, Spirituality, Medical, Emotional Well-Being, Substance Use/Other Addictions, Suicide, and Services Needed/Other Needs.

After an initial round of 23 interviews, it became clear that the original interview guide was not tapping into certain experiences that the CAB thought were important to reflect in this study. Specifically, there was little information gathered about respondents’ experiences with transitioning, and the sample’s responses did not reflect many experiences unique to individuals with Two-Spirit identities. This seemed to be an oversight of the original interview guideline and sampling. Two-Spirit individuals’ experiences may have some overlap with non-Native transgender identities but also differ in important ways, and vary by tribe as well (Lang, 2016). Thus, a second round of interviews with seven new participants targeted questions around Transitioning and Two-Spirit experiences in addition to the original interview questions. As with the first interview guide, the Partners participated in establishing the second interview guide in a process of literature review, discussion of important constructs to capture, and a review and fine-tuning of the final interview guide (see Appendix).

Sampling and participant recruitment

To locate transgender adults (age 18 and older) and request participation in interviews, we attempted to utilize snowball sampling (Guest, MacQueen, & Namey, 2011). This process entails the interviewer asking participants to recommend other potential participants as a beneficial means and method for accessing participants from a hard-to-reach population. However, participants were reluctant to disclose other transgender persons’ names, although they were willing to pass on information about our project to other transgender persons they knew. As a result, we did not recruit any participants through this process. Thus, our original sample (n = 23) was obtained through requests for participation on our website as well as via social media, Craigslist advertisements, advertisements on our community partnerships’ websites, and flyers about our project distributed at transgender-welcoming businesses (e.g., coffee shops, electrologists, Pride events, a statewide transgender conference, and transgender support groups). As some gender variant persons (e.g., those who are gender nonconforming or identify as genderqueer) do not identify as transgender, the Partners made the decision to recruit only persons who self-identify as transgender.

Transgender persons in rural areas tend to be guarded because of experiences of discrimination (Snively, 2004) and are likely concerned about potential adverse effects of a stigmatized identity being the focus of a research project. We addressed this concern by having the Project Coordinator, a member of the community, contact participants and conduct all interviews. Perceived similarities between interviewer and participants can allow for more disclosure as comfort of the participants and rapport between the parties increase (Rhodes et al., 2010). The interviewer made efforts not to ask “leading” questions and exercised caution in order to increase the objectivity of the interview. The aim was to avoid influencing how free participants felt to share their experiences and to enable themes to develop organically rather than through directive questioning.

Because the Project Coordinator served as the single interviewer, she underwent extensive interviewer training with the Primary Investigator. Additionally, the Principal Investigator reviewed several initial interviews, and helped the Project Coordinator further refine the interviewing techniques most appropriate to the project. The Principal Investigator remained involved in interview review throughout data collection to ensure proper interview skills were employed.

Following analyses of the initial data, we identified a few key emergent themes, namely Two-Spirit Experiences and Transitioning, each of which required further validation. In order to address the second interview guide’s domains, follow-up interviews were conducted with seven Two-Spirit and transgender residents of rural communities in Montana. These additional participants were recruited successfully via snowball sampling. We continued sampling until we achieved thematic saturation (i.e., no new data were starting to emerge), in accordance with the principles of a grounded theoretical approach (Strauss & Corbin 1998).

Procedure

After we received University Institutional Review Board approval and participants gave informed consent, the Project Coordinator conducted in-depth, face-to-face interviews with participants at a private location of their choice.

Data Analysis

A hired transcriptionist transcribed the data. This individual signed a confidentiality agreement and was not otherwise engaged in the research process. The second author conducted grounded theory analysis, which allowed new themes to emerge from the data that may not have been included in ecological theories to date. Grounded theory attends to meanings, themes, and patterns that may be explicit or covert in interview data (Charmaz, 2006; Glaser & Strauss, 1967). By building a theory directly from the words and experiences of participants, grounded theory privileges the voices and perspectives of participants rather than those of the researcher(s). In this way, a grounded theory approach is in alignment with the principles of CBPR in that it facilitates close involvement of community members and participants and encourages their contributions in the development of theory. The second author was brought on as a third-party researcher in the hopes of reducing bias in the analytical process; she is neither from Montana nor is she a part of the transgender community.

For this study, data analysis began with line-by-line open coding of interview transcripts. In accordance with the principles of a CBPR approach, initial open codes were validated with review and input from members of the CAB. After receiving the data analysis, the CAB met several times, including a full-day retreat. As a reliability check, a random sample of 10% of the text in the interviews was coded independently and compared to the original results. The second author then worked with members of the CAB to resolve any discrepancies or questions they had identified in their review of the initial open codes. These discussions took place at monthly CAB meetings and resulted in only minimal modifications to the open codes. After finalizing these codes with the CAB, the second author then identified and linked related codes to form broader analytic categories or axial codes. Axial codes were in turn linked and organized as key themes to address the overarching questions of the study. The most commonly cited themes and subthemes are reported in the results section, with all having at least 10 participants endorsing the theme or subtheme. The one exception to this is the subtheme related to the Two-Spirit experience. Given the smaller sample size of this hard-to-reach population, we report the salient subtheme to emerge from these interviews as a way of capturing aspects of this unique identity, as well as ensuring representation of the Two-Spirit perspectives and experiences.

Researcher Biases

Bias is inherent to any research project. Given that the Principal Investigator and the second author do not identify as transgender, great lengths were taken to ensure that potential biases were mitigated. The CAB served as the primary means of obtaining community input throughout the research process and they were intimately involved and consulted from project inception to review. Their involvement contributed significantly to informing the direction and fairness of the project. The Project Coordinator’s connection to the community enhanced data collection and mitigated possible exploitation of a vulnerable population. In addition to extensive training, she also received close supervision and oversight from the Principal Investigator throughout data collection.

Given that the Project Coordinator and others on the research team have an “insider” status with the transgender population in Montana, there is the potential that this status did influence or could have influenced the findings. Research has demonstrated that it may be beneficial to have both an “insider” and an “outsider” conduct interviews because of the unique perspectives of each position (Dwyer & Buckle, 2009). Differences between interviewer and participant can uncover insights that are often omitted or glossed over as common knowledge when the two individuals share a similar background or perspective. Our CAB believed very strongly that because we were interviewing a vulnerable population, the most successful approach was to have an “insider” conduct the interviews without the accompaniment of an “outsider.” In an attempt to address possible biases that might arise as a result of an exclusively insider-led interview, the interview guide was informed by non-insider partners, and Atlas.ti data analysis was used to build the grounded theory. Both of these strategies helped to contribute “outsider” perspectives to data collection and analysis. Therefore, input from third-party consultants from outside Montana and the transgender community, including the second author who was charged with conducting the data analysis, complemented the influence of the CAB.

Results

In two rounds of qualitative interviews, participants reported on their experiences of being transgender and the factors that influence their mental health and well-being. Data analysis resulted in three major themes, each with its own attendant subthemes. The results are summarized in Table 1 and 2. Table 1 provides a summary of the sample and their demographic characteristics. Table 2 enumerates the resultant three key themes as well as each theme’s auxiliary subthemes. Pseudonyms are used to refer to individual participants.

Table 1.

Descriptive Analyses

Characteristics	Participants (N=30)
	n	%
Gender identifieda
Male	9	30.0
Female	15	50.0
Non-binary	6	20.0
Two Spirit	2	6.7
Gender assigned at birth
Male	17
Female	13
Race/Ethnicityb
Caucasian	23	76.6
Part Native American	2	6.7
Native American	1	3.3
Native American, Indigenous, Mestizo, Mixed	1	3.3
Hispanic	1	3.3
Latino American	1	3.3
Caucasian Pacific Islander	1	3.3
Education
Some high school	2	6.7
High school degree/GED	15	50.0
Associate’s degree	1	3.3
College degree	9	30.0
Master’s degree	2	6.7
Ph.D./Professional degree	1	3.3
Relationship status
Single	10	30.0
Single/divorced	4	13.3
Partnered	3	10.0
Partnered/divorced	4	13.3
Married	3	1.0
Married/divorced	5	16.7
Separated	1	3.3
Employment
Unemployed	7	23.3
Employed part-time	6	20.0
Employed full-time	13	43.3
Retired	1	3.3
Semi-retired	1	3.3
Disability	1	3.3
Volunteer only	1	3.3

^aGender Identities are not mutually exclusive as some individuals self-identified in more than one category.

^bRace/Ethnicity responses were self-described by the participants.

Table 2.

Qualitative Findings-Themes and Subthemes

Key theme	Subthemesa	n, %
Societal and community-level factors	Linking rural environment with conservative community attitudes and discrimination.	22, 73.3
	Impact of community policies on well-being	10, 33.3
	Impact of workplace policies on well-being.	10, 33.3
	Barriers to accessing general and mental health services.	18, 60.0
Interpersonal factors	Impact of support from family and friends on mental health and well-being.	30, 100.0
	(Re) building own support network through transition.	20, 66.6
	Redefining sexuality and intimate relationships.	20, 66.6
Impact of society, community, and interpersonal factors on individual factors—specifically mental health and well-being throughout the transition process	Gender policing and bullying	26, 86.6
	Impact on well-being before, during, and post-transition.	24, 80.0
	Cultural significance of Two-Spirit identities and well-beingb	7, 23.3

^aThe cutoff for subthemes was n = 10.

^bAlthough only 7 individuals endorsed this subtheme, we report it to ensure the representation of Two-Spirit perspectives and experiences.

Descriptive Information

A total of 30 participants were interviewed for this research. Table 1 provides a summary of the demographics for the sample. The age range was 18–67 years old (M = 36.0, SD = 15.4). All participants had medically and socially transitioned to their correct gender (e.g., taking hormones, undergoing gender confirmation surgeries, and/or having changed the gender designation on their identification documents), or were in the process of transitioning. Participants self-identified as transgender female (male to female; MTF), transgender male (female to male; FTM), non-binary (which includes both male to non-binary and female to non-binary), or Two-Spirit. Non-binary (or genderqueer) is a term for gender identities that are not categorized as either male or female. Non-binary may include being on a gender spectrum, not identifying with any gender, or identifying with multiple genders. Two-Spirit is a term used to describe indigenous individuals whose gender roles, gender expressions, and/or sexual orientations transcend typical gender expectations. As mentioned above, the exact meaning, roles, and terminology for these individuals may vary by tribe.

When asked about suicidality, 24 participants (80.0%) reported having past suicidal ideation and 14 participants (46.7%) reported having made past attempts (and reported stopping or having been stopped in the process of attempting). All participants denied having current suicidal ideation, intent, or plan.

Qualitative Findings

Analysis of the interview data revealed that societal and community-level factors, and factors related to everyday interactions within social networks, are perceived to influence the mental health and well-being of participants directly. Findings are organized to highlight the ways in which systemic forces shape interpersonal interactions, individual mental health, well-being, and suicidality. Furthermore, grounded theoretical analysis suggested a high degree of interplay across the different levels of the ecological framework (societal, community, interpersonal, and individual), which in turn impacted the degree to which participants were able to access health and mental health services within their communities. Table 2 summarizes the key themes and subthemes that emerged from the analysis of the interview data.

Societal and Community-level Factors

Participants spoke at length about the impact of societal and community-level factors including the rural environment, politics, work, and healthcare on their well-being. Participants linked orthodox religious beliefs with conservative political climates, which in turn led them to feel unsafe and unaccepted within their communities. Additionally, participants elaborated on their experiences with discrimination at work, and their challenges in accessing general and transgender-specific healthcare services. Participants explained the degree to which these community-level factors directly impacted their feelings of comfort, belonging, and general well-being. Our participants made additional recommendations that youth receive education about gender identity and gender diversity so that individuals grow up with some familiarity and knowledge regarding gender diversity.

Linking rural environment with conservative community attitudes and discrimination

Participants acknowledged that residents in rural communities in Montana tend to be very conservative in terms of their religious and political views. As participants explained, this conservatism made being “out” as a transgender person in the community challenging. They reported experiencing anxiety related to going out in public, and an overall reduced sense of belonging in their community.

[This community] is very conservative. And they’ve been moving, swinging in even more conservative directions. But there’s also these people who have moved in from outside who, I think, have a much more open and liberal viewpoint. And they are in a small minority…. I’ll be the butt of jokes. [Clarence]

Participants also explained that the general prevalence of conservative attitudes within their communities led them to feel unsafe in a range of public spaces, from bars and restaurants to local stores (e.g., Walmart).

Impact of community policies on well-being

Participants who lived in larger communities, or communities containing a university, reported feeling safer and more comfortable living out as their gender identity compared to those living in smaller communities or places without a university. Participants in larger communities also acknowledged that the political discourse in these locations tended to be more liberal, and residents were more likely to support nondiscrimination ordinances (NDOs) or other policies intended to protect the rights of trans individuals. Not only did participants perceive NDOs to provide legal protection, they also described how these ordinances often felt symbolic, signifying support for the trans community. In contrast, in communities that lacked NDOs, participants reported a greater sense of anxiety related to being out as transgender, and feeling more like outcasts in their communities.

I suppose [lack of NDOs] creates more general anxiety, knowing that there aren’t a lot of protections for trans people in general. Not that I would necessarily do anything to go to prison or whatever, but knowing that there’s a good possibility that I’d be put in the male prison is stressful. Yeah. Same thing with work discrimination. [Jenny]

Impact of workplace policies on well-being

Many participants noted that the lack of NDOs in their community meant they had no legal protection from workplace discrimination and job loss that could result because of their gender identities. Several participants reported experiencing discrimination and harassment from their supervisors and co-workers, which they attributed to their gender identity. This discrimination entailed the daily experience of microaggressions, name-calling, and exclusion from workplace events or social gatherings. All participants who reported such discrimination linked these experiences with feelings of anxiety and depression, and noted that their experiences adversely impacted their ability to live fulltime as their gender.

Well, one of my jobs doesn’t want me showing up being me. Since I make a couple of people uncomfortable, they don’t want me going to work like that at all…Even if I’m not working…just being a regular customer, I can’t even go…It makes me depressed. It makes me think that…I’m not worth being a human half the time. How is who I am gonna base how I work? Is that how you’re basing it? How I identify, does that really base how I work? [Cora]

Barriers to accessing general and mental health services

Participants described several barriers to accessing both general healthcare services, as well as mental health services. Broadly, these barriers included a dearth of providers in rural communities trained to address the specific healthcare needs of transgender individuals, experiences of discrimination from healthcare providers, and a lack of insurance coverage for transgender-specific services. These barriers have adversely impacted the willingness and ability of participants to access healthcare services - both for general health as well as transgender-specific healthcare. With regard to accessing general healthcare services, participants reported a high degree of dissatisfaction, citing several instances of discrimination from healthcare support staff and an overall lack of provider knowledge, experience, and comfort in treating transgender patients.

I kind of feel like I keep getting passed off with things that aren’t related to being trans, especially by the doctor who I feel like should be handling these situations…I’ve been getting bounced back and forth as to who I should be seeing just because they don’t know how to deal with it…My insurance - they won’t cover any doctors’ visits related to transitioning. I’ve definitely been…I don’t know if it’s necessarily depressed but frustrated, especially when I have to go to a doctor. I’m like, “I don’t want to because I’m just going to be told this same thing again.” [Dennis]

I think that a lot of [providers] are very ignorant about a lot of the transgender stuff. Like my primary doctor, I went there for a physical, and she was like, “So if you’re a man now, do I still have to do things like a breast exam? A pap smear? What do I have to do?”...I felt like I had to play doctor for her... [Clarence]

In addition to general healthcare, participants also noted challenges accessing mental health services within their communities, specifically citing a lack of mental health professionals with the requisite training and experience to counsel transgender individuals. Moreover, participants reported financial barriers to mental health treatment, noting that insurance often did not cover these services. Participants who reported positive interactions with mental health providers linked these experiences with overall improved psychological health and well-being. However, participants reported having to do extensive background research to find practitioners who were trained and experienced in counseling transgender individuals; in many cases, participants had to travel far outside their community to see these practitioners because there were no providers in many of the smaller, rural communities where participants reside.

Interpersonal factors

Participants who medically and socially transitioned described a number of interpersonal factors that impacted their mental health and emotional well-being throughout the transition process. They described social support they received from family, intimate partners, friends and allies, as well as online social communities. Although the presence of these types of social supports contributed overall to improved mental health and well-being for some participants, others described how they had to recreate and rebuild a support network – one that was supportive of their new gender identity – from pre- to post-transition.

Impact of support from family and friends on mental health and well-being

When reflecting on the process of coming out as transgender and transitioning, participants acknowledged that the support of their family and friends was of paramount importance to their general health and well-being. Several participants reported feeling a sense of anxiety and fear related to their expectations that disclosing to their family would not go well. Aidan explained: “My relationship with my family is very important…but for kind of the sake of self-preservation, I haven’t pursued [disclosing to them] a lot. I would like to have a stronger relationship with them, but it’s really tough.”

Similarly, participants reported feelings of sadness and loss when friends and others in their social network were not supportive. Many people reported losing friends during and after their transition:

What I lost saddened me. I was very sad to lose these people, but it also made me realize that the friendship that I had with them was probably false and based on false assumptions…a very surface assumption of being, and that sadness really affected me greatly... Losing these close friendships. I had known them longer than I had known my son. So the loss of those people was very disheartening, saddening, and I cried about it. [Maria]

However, participants reported varying degrees of support from their immediate and extended families, with several describing high levels of support. Participants who reported strong family support throughout their transition linked this support to improvements in their mental health and emotional well-being.

[My relationship with my family] actually became stronger because in the Crow tribe, those that are part of the Two-Spirit group, they tend to be held in a higher esteem. Because they have that duality; they have that knowledge of both and a lot of the Two-Spirit people throughout history have been very strong in medicine and helped the tribe... My status has changed a little bit just because I am transgendered. [Taylor]

Nonetheless, participants reported a need for support groups for transgender persons and their families.

(Re)building own support network through transition

Among participants who reported a lack of support from family and/or friends, many indicated that they had built a new support network throughout the transition process instead. As participants explained, this process of building a support network entailed strengthening relationships with those family members and friends who were supportive, creating a chosen family, and making new friends who were supportive and understanding of their transgender, non-binary, or Two-Spirit identities. Participants also noted that, given the small population in rural communities, social media sites have provided an important means of supplementing their network of transgender friends and allies:

A lot of [my social network] is like social media. Like Facebook. I’ve actually got about half my friends on Facebook are all trans. There are different trans groups on Facebook. I have a MeetMe account, and like my information that I am transgender, and I just want to be known for who I am and going to be. I’ve got a good friend list on that one too. A lot of supportive people. [Joseph]

Redefining sexuality and intimate relationships

Participants acknowledged the impact of their transition on their sexuality, dating, and relationships with existing intimate partners. Participants who were dating acknowledged challenges in finding and disclosing to potential partners, particularly in rural communities where residents may not be as open to dating a transgender person. Here, participants similarly cited the value of social media sites in finding partners:

[Being trans] definitely poses a challenge…nowadays, I feel like dating is just online. Like I don’t know how to even meet people besides online…which is totally different than the last time I did it, but that’s just how it’s done, so okay…Like I said, you can just not put anything in there, but then when you do that, basically you need to have this really awkward and sometimes intense conversation with the other person before ever meeting them about that. You basically tell them, and more often than not, that’s a deal breaker. That’s just not what they’re looking for. At all. And so that can be pretty hard. [Hilda]

For participants who were in committed relationships at the time of their transition, the process of both coming out to their partner and of transitioning sometimes led to the dissolution of the relationship. In other cases, participants reported that their transition had improved the quality of their relationship with their partner, explaining that they felt their gender identity was validated through their partner. Participants explained that this validation led to a greater degree of honesty and intimacy in their relationships, and ultimately helped improve well-being for both themselves and their relationships.

Now I have an absolutely wonderful social support system. I have a very supportive wife who sees me for exactly who I am and absolutely no secrets from her. She has helped me immeasurably in my transition. Helps me shop, identify, dress, all the feminine things…. It is a very loving relationship, a very supportive relationship. And if I didn’t have that, my daily life could get very ugly. How I am as my identified gender…the relationship supplements and reinforces my work and my idea of self. [Danielle]

Impact of societal, community and interpersonal factors on individual health and well-being

All participants acknowledged the ways in which the combination of societal, community, and interpersonal factors directly impacted their individual health and overall well-being. Specifically, participants noted the ways in which their experiences of discrimination, gender policing and bullying, and a general feeling that they did not belong had contributed to mental health challenges and overall well-being.

Gender policing and bullying

Related to their experiences living and growing up in rural communities with conservative attitudes, nearly all participants noted that they had experienced some form of gender policing, up through their adolescence and into adulthood. Most commonly, this took the form of bullying from classmates, attempts by parents and other family members to control or change participants’ gender expression, and harassment within the community. Participants linked their experiences with gender policing and harassment to adverse mental health outcomes. Many reported a wide range of mental health diagnoses, including depression and associated suicidal ideation, obsessive-compulsive disorder (OCD), social anxiety disorder, bipolar disorder, dissociative personality disorder, schizo-affective disorder, and paranoid schizophrenia, among others. Moreover, participants indicated that the ongoing threat of gender policing or harassment resulted in a reduced feeling of belonging within their community.

Even before I came out…I’ve always been kind of a target...I definitely get a lot of stares. I’ve been egged in town….it has actually reduced my sense of belonging here. When I moved back, I’m like this isn’t my childhood home. [Aaron]

Collectively, participants’ shared experiences of gender policing and bullying highlight the ways in which conservative community attitudes – as discussed earlier – manifest in the day-to-day realities and lived experiences of transgender persons in rural communities.

Impact on well-being before, during, and post-transition

Participants explained how their mental health and overall well-being were particularly poor prior to their transition, as they believed that they were, in the words of some, “not being true” to their identity, or feeling like they were “living a lie.” Participants also acknowledged that their suicidal ideation was particularly prevalent and prominent leading up to their transition, but had decreased considerably since they decided to go through transition and live as their gender:

[Suicidal ideation] has been an off and on battle. I think the first thought of that I ever had was actually in middle school. Because I thought something was wrong with me, and I felt like the easiest way to deal with that would be to just eliminate myself from the situation…. Since I’ve come out [as transgender], it’s been a lot less of the suicidal thoughts, which has been a huge jump forward. [Gordon]

Participants who had made the decision to come out as transgender and live fulltime in their gender identity also reported significant improvements in their physical and mental health, emotional well-being, and a renewed desire to care for themselves.

Getting my mental health under control has helped with my physical health in that I’m much more active and eat better and all that…This is kind of the first period in my life that I’ve ever focused on myself in trying to do what is best for me instead of for other people. [Riley]

I would say my current physical health is better. Better than it’s been in the past if for no other reason [than transitioning], I have a lot less stress in my life now. So I feel better than I’ve ever felt. That’s just like an overall wellbeing feel better, but I think a lot of that has to do with stress and the lack of it in my life now. Versus before knowing that you need to do this thing [transition], but you’re not doing this thing and just stressed about coming out to people and stuff like that. Now that that’s kinda not there at all, I feel great…The first time I came out to somebody, it was like the biggest breath of fresh air. It was just a complete release. [Danielle]

Participants who reported improvements in their general health and well-being also reported having a strong network of friends and/or family to support them through the process.

Cultural significance of Two-Spirit identities and well-being

Participants who identified as Two-Spirit indicated that their identity is not entirely equivalent to a transgender identity. Rather, they described the identity as being more fluid, and meaning different things to different tribes and individuals. Participants noted that although some Two-Spirit individuals experience discrimination within their tribes, historically this identity has been respected within many Native traditions and spiritualties. In some of these traditions, a Two-Spirit individual plays a “healing” role. These participants indicated that knowledge of the historical and cultural importance of the Two-Spirit identity helped them to embrace their own sense of self, and improved their overall sense of confidence and well-being in relation to that experience.

[For] the Crow tribe, back before the pre-reservation days, when a child was born, they weren’t assigned male or female. When a child was born, they have a child…The reason why Two-Spirit people are at a higher level, is…a majority of the Two-Spirit people in our history had medicine. Had powers and stuff like that. And [the members of the Crow tribe] see them as wiser…because there is that status of medicine in the background…they have more of a, a little bit more of a history than just regular members of the tribe. [Garret]

Discussion

Our findings highlight the significant unmet mental health needs of transgender persons living in rural Montana. In our sample, the number of participants who reported suicide ideation and suicide attempts prior to coming-out and/or transitioning was alarming. Unfortunately, these alarming rates are not exceptions to the rule for transgender individuals, as shown by elevated suicide risk nationally (James et al., 2016). The risk for suicidal behavior seemed particularly acute for those who were unable to actualize their gender identity or were early in their transition. The determinants of suicide risk appear to be multifaceted and occur on multiple ecological levels. Relatedly, participants acknowledged a broad range of mental health diagnoses and decreased well-being prior to and early on in their transition process. These results highlight the additional risks for rural transgender individuals, who are subject to gender policing, bullying, discrimination, and marginalization.

Participants described the influence of societal and community-level factors on their well-being. These factors included the rural environment, politics, work, and healthcare. Many participants linked orthodox religious beliefs with conservative political climates, which in turn led them to feel unsafe and unaccepted within rural communities and at their places of work. As Perez-Brumer and colleagues (2015) noted, “living in more stigmatizing communities” may enhance experiences of increased stress in transgender persons, which in turn may result in increased suicidal ideation and attempts (p. 169). Two-Spirit individuals described the tension between living in a broader society that stigmatizes transgender identities, while being from tribes that historically honor Two-Spirit identities. These individuals described how the cultural significance of Two-Spirit individuals served as a protective factor for their overall well-being.

Additionally, participants described challenges in accessing general and transgender-specific healthcare services, including overt discrimination by mental health and healthcare providers. Participants indicated that several providers would not treat them for reasons including personal bias, lack of knowledge and/or experience, and discomfort providing transgender care. Participants also reported that they often had to provide education about transgender persons and their needs to their medical providers. Cruz (2014) stated that the stigma transgender persons encounter when seeking healthcare has created a need to receive special considerations in addressing access to primary care issues. Hughto, Reisner, and Pachankis’s (2015) review of stigma toward transgender populations also highlights how “transgender stigma limits opportunities and access to resources in a number of critical domains (e.g., employment, healthcare), persistently affecting the physical and mental health of transgender people” (p. 222). Our findings, too, summarize the connections that participants made between their well-being, in addition to that of other transgender persons, and access to appropriate medical and mental health care. Consistent with previous research, participants in this study stated that their well-being improved, when they were able to transition in a way that fit for them and when they had support through this process (Keo-Meier et al., 2013). Improvements in mental health also were noted, as well as reductions in suicidal ideation.

In sum, the nonexistence of NDOs as well as a shortage of providers both appear to be societal and community level factors that suggest a widespread lack of understanding and recognition of transgender struggles, needs, and experiences in rural Montana. Most significantly, the absence of adequate care can have deleterious effects on the mental health of transgender people, including increases in suicidality.

The study also highlights another important theme: that familial and social relationships were of paramount importance to transgender persons. Participants reported suffering losses of relationships from the disclosure of their gender identity during their transitions, and experiencing grief and decreased support because of those losses. They also described challenges inherent in maintaining intimate relationships that predated transition. For those seeking to date in their rural communities, these individuals reflected on the difficulties of navigating the tricky and fear-inducing process of disclosing to others that they are transgender. However, participants also described the resilient creation of new relationships including forming new “families,” and joining support systems via online forums and social media sites.

Strengths and Limitations

There are limitations to this research. First, although we aimed to recruit persons in various stages of transition including those who are currently living as their assigned gender, it was challenging to locate transgender persons who are “hidden” because they choose not to or are unable to transition. Second, our method of recruiting participants resulted in a limited sample. That being said, the process of recruitment built trust within the larger transgender population, which was an important goal of our project. Third, the large majority of our participants were White, which, though consistent with Montana’s demographics (U.S. Census Bureau, 2014), is not representative of the broader transgender population. Therefore, our findings may not map onto the experiences of transgender persons of color or with additional intersecting identities. Fourth, part of the research team has an “insider” status with the transgender population in Montana, which could influence the findings. However, based on the CAB’s contention that an “insider” should conduct the interviews, steps were taken to introduce “outsider” perspectives to data collection and analysis through partnership with third-party partners, who were not affiliated with either Montana or the transgender community. Finally, at this stage, our project was focused on hearing the stories of individual participants’ life experiences. A future study using a larger-scale, mixed-method design and quantitative assessment measures of internalized transphobia, social support, mental health, and suicidality, would provide a wealth of additional information.

There are multiple strengths to this study. This study is the first, to the authors’ knowledge, that addresses rural transgender suicidality and is responsive to a need identified by both the Montana transgender community and the existing literature (Cochran & Mays, 1994; Meyer, 1995; National Academies of Sciences, Engineering, and Medicine, 2015; Richmond et al., 2012; Rosario, Scrimshaw, & Hunter, 2009; Sandfort et al., 2001). Also, using a CBPR approach has allowed this study to be more culturally appropriate, helpful, and respectful to the community being studied. We gained new understanding for the complexity of factors influencing suicidality among transgender individuals in a rural state and this project built trust statewide within the transgender community.

Conclusions and Implications for Future Research and Action

It is important to emphasize not only the high rate of suicidality of our sample when they were pre-transition, but also that despite a decrease in suicidality and an increase in mental and physical health after transition, our participants clearly and consistently described ongoing discrimination, stigma, and marginalization in their daily lives. Prejudicial views, stigma, as well as discriminatory behavior and social and legal policies that neglect human rights compromise the wellness of transgender persons. Miller and Grollman (2015) found that, consistent with prior research (Clements-Nolle et al., 2006; Pascoe & Richman, 2009), transgender people who face more discrimination every day and experience major types of discrimination are more likely to engage in health-harming behaviors (e.g.., attempted suicide, drug/alcohol abuse, and smoking). These same authors also concluded that the minority stress model can be applied to comprehend the social determinants that adversely impact transgender health (Meyer, 1995, 2003). In addition to the known factors, such as family and social support (Nemoto et al., 2011), optimism, reasons for living, and resilience (Moody & Smith, 2013), additional research is needed to identify additional factors that minimize suicide risk for transgender individuals.

This study highlights the need for additional research to further evaluate the impact of policies at statewide and local levels that do not support human rights. In addition, because medical and mental health professionals often are not trained in or comfortable with transgender medical needs, training programs for healthcare providers need to incorporate transgender-specific issues as part of their clinical training (Cochran, Reed, & Gleason, 2017). This study highlights the need for several community and systemic changes that would decrease the adverse impacts of transphobia and marginalization on the health of transgender individuals. It is essential that we increase our understanding about determinants impacting rural transgender mental health, and that we pair this understanding with action to address the factors that increase suicide risk for transgender persons. Without such understanding and action, the quality of care and support provided for transgender individuals is unlikely to improve.