INTRODUCTION
Research has consistently documented a high burden of adverse mental health outcomes among transgender persons (1–3). Among transgender women specifically, a high prevalence of both depression and suicidality have been reported (4–5). Prevalence of current/past-year depression in community samples of transgender women has ranged from 18.2% to 62%, compared to 7.1% in the US population (4, 6–12). Past-year suicidal ideation and attempts have rarely been assessed among transgender women, but a recent study of transgender women living with HIV found past-year suicidal ideation at 15.6% and past-year suicide attempts at 7.8%, compared to 4.3% and 0.6% among the overall population in the US, respectively (6–7). In addition, one study of persons living with HIV found that past-month suicidal ideation prevalence was 21.3% and past-month suicide attempt prevalence was 2.0% (13). Lifetime suicidal ideation has ranged from 53% to 56% among transgender women, compared to between 8.4% and 9.7% among all adults in the US, suicide attempts have ranged from 28% to 40% among transgender women compared to 4.6% other adults in the US (1, 10, 12, 14–17).
Gender identity-related stigma and associated social determinants of health may contribute to adverse mental health outcomes and may limit access to health care services for transgender women (18–19). While minority status stress processes can be interpersonal, institutional, and structural, consisting of experiences of mistreatment, rejection, discrimination, and violence from others (e.g., enacted stigma), they can also be intrapersonal, consisting of perceptions or expectations of being or having been mistreated, rejected, discriminated against, or treated with violence (e.g., perceived stigma, anticipated stigma) (20). Limited scholarship has examined how perceived and anticipated gender identity-related stigmas are associated with mental health outcomes among transgender women. In addition, there is a dearth of research on the potential impact of stigma related to other socially marginalized attributes or behavior, e.g., sexual behavior, among this population. A range of sexual identities and behaviors are commonly stigmatized, regardless of gender identity (21). However, sexual acts between people who are not heterosexual and not cisgender may be particularly stigmatized and may strongly influence mental well-being.
We conducted a cross-sectional pilot study to assess various types of gender identity stigma, sexual behavior stigma, and mental health among transgender women in the US. Our study aimed to (a) document the prevalence of past-year severe psychological distress, suicidal ideation, and suicide attempts, and (b) examine associations between mental health outcomes and perceived, anticipated, and enacted stigmas related to both gender identity and sexual behavior.
METHODS
Participants were recruited through convenience sampling from websites and through social media applications using banner advertisements or email blasts to members. Those who clicked on ads are taken directly to the survey website hosted on a secure server administered by SurveyGizmo (Boulder, CO, USA) where they were screened for eligibility. All individuals aged 15 years or older who identified as transgender women or transfeminine and who resided in the US were eligible. Those who provided informed consented immediately started the self-administered questionnaire. Survey respondents were not required to provide any directly identifying information but were asked to provide ZIP code which was used to determine area of residence. No incentive was provided for survey participation. Data were collected from March through May 2019. The study protocol was approved by the Institutional Review Board at <blinded for peer review>.
Perceived, anticipated, and enacted stigmas as a result of (a) gender identity and (b) sexual behavior were measured by asking participants two sets of 13 questions (Table 1). The sexual behavior stigma scale has been previously used in other populations and in other settings (e.g., 22–25). The internal consistency of the gender identity stigma scale was acceptable (Cronbach’s α = 0.79), and the internal consistency of the sexual behavior stigma scale was good (Cronbach’s α = 0.87). In addition to examining individual scale questions, we also created a summary scale score by summing all affirmative responses to the individual questions (yes=1, no=0).
Table 1.
Measurement of gender identity and sexual behavior stigmas.
| Items | Type of Stigma | Properties | ||||
|---|---|---|---|---|---|---|
| Mean (SD) | Median | Range | Alpha | |||
| Gender Identity Stigma | (Scale) | 5.99 (2.95) | 6 | 0–13 | 0.79 | |
| Have you ever felt excluded from family activities because of your gender identity? | Perceived | |||||
| Have you ever felt that family members have made discriminatory remarks or gossiped about you because of your gender identity? | Perceived | |||||
| Have you ever felt rejected by your friends because of your gender identity? | Perceived | |||||
| Have you ever felt afraid to go to health care services because of your gender identity? | Anticipated | |||||
| Have you ever avoided going to health care services because of your gender identity? | Anticipated | |||||
| Have you ever felt that you were not treated well in a health center because of your gender identity? | Perceived | |||||
| Have you ever heard health care providers gossiping about you (talking about you) because of your gender identity? | Enacted | |||||
| Have you ever felt that the police refused to protect you because of your gender identity? | Perceived | |||||
| Have you ever felt scared to be in public places because of your gender identity? | Perceived | |||||
| Have you ever been verbally harassed and felt it was because of your gender identity? | Enacted | |||||
| Have you ever been blackmailed by someone because of your gender identity? | Enacted | |||||
| Has someone ever physically hurt you (pushed, shoved, slapped, hit, kicked, choked or otherwise physically hurt you)? [AND] Do you believe any of these experiences of physical violence was/were related to your gender identity? | Enacted | |||||
| Have you ever been forced to have sex when you did not want to? (By forced, I mean physically forced, coerced to have sex, or penetrated with an object, when you did not want to). [AND] Do you believe any of these experiences of sexual violence were related to your gender identity? | Enacted | |||||
| Sexual | (Scale) | 2.43 | 2 | 0–13 | 0.87 | |
| Behavior Stigma | (2.83) | |||||
| Have you ever felt excluded from family activities because of who you have sex with? | Perceived | |||||
| Have you ever felt that family members have made discriminatory remarks or gossiped about you because of who you have sex with? | Perceived | |||||
| Have you ever felt rejected by your friends because of who you have sex with? | Perceived | |||||
| Have you ever felt afraid to go to health care services because of who you have sex with? | Anticipated | |||||
| Have you ever avoided going to health care services because of who you have sex with? | Anticipated | |||||
| Have you ever felt that you were not treated well in a health center because of who you have sex with? | Perceived | |||||
| Have you ever heard health care providers gossiping about you (talking about you) because of who you have sex with? | Enacted | |||||
| Have you ever felt that the police refused to protect you because of who you have sex with? | Perceived | |||||
| Have you ever felt scared to be in public places because of who you have sex with? | Perceived | |||||
| Have you ever been verbally harassed and felt it was because of who you have sex with? | Enacted | |||||
| Have you ever been blackmailed by someone because of who you have sex with? | Enacted | |||||
| Has someone ever physically hurt you (pushed, shoved, slapped, hit, kicked, choked or otherwise physically hurt you)? [AND] Do you believe any of these experiences of physical violence was/were related to who you have sex with? | Enacted | |||||
| Have you ever been forced to have sex when you did not want to? (By forced, I mean physically forced, coerced to have sex, or penetrated with an object, when you did not want to). [AND] Do you believe any of these experiences of sexual violence were related to who you have sex with? | Enacted | |||||
Response options: 0—no or 1—yes.
Severe psychological distress in the past month was measured as a score of ≥13 using the Kessler 6-question assessment (26). Suicidal ideation in the past year was measured by a single question: “In the past 12 months, up to and including today, did you seriously think about trying to kill yourself?” Suicide attempts in the past year was measured with one question: “During the past 12 months, did you try to kill yourself?”
A series of modified Poisson regression models with log links and robust variance estimators were used to produce prevalence ratios and 95% confidence intervals for unadjusted and adjusted associations between demographic characteristics, gender identity stigma, and sexual behavior stigma with severe psychological distress, suicidal ideation, and suicide attempts. Each of the 13 gender identity stigma scale items, as well as each of the 13 sexual behavior stigma items, were treated as exposures in separate models, as were the gender identity stigma and sexual behavior stigma scales. Each model with each individual stigma item (or scale) was first fit without covariates, and those that were significant at the p < 0.10 level were then fit with covariates. Which covariates to include in which models were determined based on which demographic characteristics were associated the mental health outcome of interest (i.e., severe psychological distress, suicidal ideation, or suicide attempt, depending on the model that was fit) at p < 0.10. The level of significance for the adjusted models was p < 0.05. All models were fit using Stata 15.1 (College Station, Texas, USA).
RESULTS
Of the 381 transgender women who were enrolled and completed the questionnaire, most were 15–29 years, white, non-Hispanic, completed at least some college, made under $40,000 annually, and identified as bisexual, pansexual or queer (Table 2). Most participants (363/381, 95.28%) endorsed at least one item on the gender identity stigma scale, and 341/381 (89.5%) participants endorsing two or more items. Two-hundred and fifty-seven (67.45%) participants endorsed at least one item on the sexual behavior stigma scale, with 194/381 (50.92%) endorsing two or more items.
Table 2.
Prevalence and correlates of severe psychological distress among US transgender women in the TWIST study, 2019.
| Characteristics | Total | Severe Distress | Psychological | PR (95% CI) | aPR (95% CI)* |
|---|---|---|---|---|---|
| Yes n=198 | No n=183 | ||||
| Age, n (%) | |||||
| 15–24 | 194 (50.9) | 120 (61.9) | 74 (38.1) | ref | |
| 25–29 | 61 (16.0) | 33 (54.1) | 28 (45.9) | 0.87 (0.68, 1.13) | |
| 30–39 | 44 (11.5) | 22 (50.0) | 22 (50.0) | 0.81 (0.59, 1.11) | |
| 40+ | 82 (21.5) | 23 (28.0) | 59 (72.0) | 0.45 (0.32, 0.65) | |
| Race, n (%) | |||||
| Black, non-Hispanic | 8 (2.1) | 4 (50.0) | 4 (50.0) | 0.96 (0.47, 1.94) | |
| Hispanic | 46 (12.1) | 23 (50.0) | 23 (50.0) | 0.96 (0.70, 1.31) | |
| White, non-Hispanic | 276 (72.4) | 144 (52.2) | 132 (47.8) | ref | |
| Other/multiple races/unknown | 51 (13.4) | 27 (52.9) | 24 (47.1) | 1.01 (0.76, 1.35) | |
| Education Completed, n (%) | |||||
| ≥College | 90 (23.6) | 36 (40.0) | 54 (60.0) | 0.75 (0.56, 1.01) | |
| Some college/AA | 150 (39.4) | 80 (53.3) | 70 (46.7) | ref | |
| HS diploma or less | 133 (35.7) | 77 (57.9) | 56 (42.1) | 1.09 (0.88, 1.34) | |
| Unknown | 8 (2.1) | 5 (62.5) | 3 (37.5) | 1.17 (0.67, 2.05) | |
| Income, n (%) | |||||
| $75,000+ | 52 (13.6) | 18 (34.6) | 34 (65.4) | 1.05 (0.39, 1.35) | |
| $40,000-$74,999 | 65 (17.1) | 30 (46.2) | 35 (53.8) | 0.77 (0.57, 1.04) | |
| $20,000–39,999 | 81 (21.3) | 39 (48.1) | 42 (51.9) | 0.80 (0.62, 1.05) | |
| $0–19,999 | 132 (34.6) | 79 (59.8) | 53 (40.2) | ref | |
| Unknown | 51 (13.4) | 32 (62.7) | 19 (37.3) | 1.05 (0.81, 1.35) | |
| Sexual Identity | |||||
| Gay or homosexual | 56 (14.7) | 23 (41.1) | 33 (58.9) | 0.72 (0.51, 1.01) | |
| Straight or heterosexual | 37 (9.7) | 11 (29.7) | 26 (70.3) | 0.52 (0.31, 0.86) | |
| Bisexual or pansexual | 169 (44.4) | 97 (57.4) | 72 (42.6) | ref | |
| Queer | 68 (17.8) | 42 (61.8) | 26 (38.2) | 1.08 (0.86, 1.35) | |
| Asexual | 6 (1.6) | 1 (16.7) | 5 (83.3) | 0.29 (0.69, 1.26) | |
| Other/unknown | 45 (11.8) | 24 (53.3) | 21 (46.7) | 0.93 (0.69, 1.26) | |
| Region, n (%) | |||||
| West | 101 (26.5) | 53 (52.5) | 48 (47.5) | 1.08 (0.83, 1.40) | |
| Midwest | 73 (19.2) | 43 (58.9) | 30 (41.2) | 1.21 (0.93, 1.58) | |
| Northeast | 88 (23.1) | 44 (50.0) | 44 (50.0) | 1.03 (0.78, 1.36) | |
| South | 119 (31.2) | 58 (48.7) | 61 (51.3) | ref | |
| Urbanicity | |||||
| Rural and small/medium city | 84 (22.0) | 47 (56.0) | 37 (44.0) | ref | |
| Urban and suburban | 297 (78.0) | 152 (51.2) | 145 (48.8) | 0.91 (0.73, 1.13) | |
| Gender Identity Stigma | |||||
| Excluded by family | 282 (74.0) | 155 (55.0) | 127 (45.0) | 1.48 (0.99, 2.20) | - |
| Gossiped about by family | 280 73.5) | 155 (55.4) | 125 (44.6) | 1.71 (1.09, 2.70) | 1.60 (1.11, 2.30) |
| Felt rejected by friends | 241 (63.4) | 139 (57.7) | 102 (42.3) | 1.38 (1.01, 1.89) | 1.33 (1.06, 1.66) |
| Afraid to seek health services | 200 (52.5) | 124 (62.0) | 76 (38.0) | 1.49 (1.12, 2.00) | 1.33 (1.08, 1.63) |
| Avoided health services | 157 (41.2) | 98 (62.4) | 59 (37.6) | 1.39 (1.05, 1.84) | 1.26 (1.04, 1.51) |
| Treated poorly in health facility | 115 (30.2) | 67 (58.3) | 48(41.7) | 1.25 (0.92, 1.69) | - |
| Healthcare workers gossiped | 80 (21.0) | 52 (65.0) | 28 (35.0) | 1.38 (1.00, 1.90) | 1.44 (1.20, 1.73) |
| Did not feel protected by police | 85 (22.3) | 51 (60.0) | 34 (40.0) | 1.30 (0.94, 1.81) | - |
| Felt scared in public | 328 (86.1) | 181 (55.2) | 147 (44.8) | 1.73 (1.04, 2.88) | 1.44 (0.99, 2.11) |
| Verbally harassed | 288 (75.6) | 157 (54.5) | 131 (45.5) | 1.42 (0.96, 2.10) | - |
| Blackmailed | 54 (14.2) | 41 (75.9) | 13 (24.1) | 1.58 (1.12, 2.24) | 1.39 (1.15, 1.69) |
| Physically hurt | 114 (29.9) | 75 (65.8) | 39 (34.2) | 1.12 (0.78, 1.60) | - |
| Forced sex | 59 (15.5) | 44 (74.6) | 15 (25.4) | 1.17 (0.77, 1.79) | - |
| Total Scale Score (GI) | - | - | - | 1.09 (1.06, 1.13) | 1.08 (1.05, 1.12) |
| Sexual Behavior Stigma | |||||
| Excluded by family | 91 (23.9) | 58 (63.7) | 33 (36.3) | 1.32 (0.97, 1.80) | - |
| Gossiped about by family | 141 (37.) | 83 (58.9) | 58 (41.1) | 1.26 (0.94, 1.69) | - |
| Felt rejected by friends | 101 (26.5) | 69 (68.3) | 32 (31.7) | 1.48 (1.11, 2.00) | 1.43 (1.20, 1.71) |
| Afraid to seek health services | 49 (12.9) | 34 (69.4) | 15 (30.6) | 1.39 (1.11, 1.73) | 1.26 (1.01, 1.58) |
| Avoided health services | 36 (9.4) | 25 (69.4) | 11 (30.6) | 1.36 (1.06, 1.75) | 1.25 (0.98, 1.60) |
| Treated poorly in health facility | 33 (8.7) | 24 (72.7) | 9 (27.3) | 1.47 (1.16, 1.86) | 1.45 (1.16, 1.82) |
| Healthcare workers gossiped | 24 (6.3) | 18 (75.0) | 6 (25.0) | 1.51 (1.17, 1.95) | 1.64 (1.28, 2.10) |
| Did not feel protected by police | 44 (11.5) | 25 (56.8) | 19 (43.4) | 1.11 (0.84, 1.48) | - |
| Felt scared in public | 126 (35.7) | 79 (62.7) | 47 (37.3) | 1.33 (1.11, 1.62) | 1.24 (1.02, 1.51) |
| Verbally harassed | 144 (37.8) | 98 (68.1) | 46 (31.9) | 1.37 (1.13, 1.66) | 1.32 (1.09, 1.60) |
| Blackmailed | 35 (9.2) | 25 (71.4) | 10 (28.6) | 1.45 (1.14, 1.83) | 1.30 (1.03, 1.62) |
| Physically hurt | 59 (15.5) | 40 (67.8) | 19 (32.2) | 1.40 (1.13, 1.73) | 1.36 (1.10, 1.69) |
| Forced sex | 34 (8.9) | 26 (76.5) | 8 (23.5) | 1.54 (1.24, 1.92) | 1.41 (1.14, 1.74) |
| Total Scale Score (SB) | - | - | - | 1.07 (1.04, 1.09) | 1.06 (1.03, 1.09) |
Demographic covariates: age, income, and sexual identity.
The mean score for the gender identity stigma scale was 5.99 (SD=2.95), and the mean score for the sexual behavior stigma scale was 2.43 (SD=2.83). The gender identity stigma and sexual behavior stigma scales were positively correlated (r=0.53).
Severe Psychological Distress
Overall, 198 (52%) participants experienced severe psychological distress in the past month (Table 2). Severe psychological distress was more prevalent among those who were younger, had lower income, identified as bisexual, pansexual or queer, lived in the West or Midwest US, and lived outside of urban/suburban areas. In unadjusted models, severe psychological distress was associated with most of the gender identity stigma items but was most strongly associated with being blackmailed, family gossip, and being afraid to seek health services. A one-point increase in the gender identity stigma scale was associated with a 9% (95% CI: 6%−13%) increased prevalence of severe psychosocial distress.
Severe psychological distress was similarly associated with most of the sexual behavior stigma items but was most strongly associated in unadjusted models with forced sex, healthcare worker gossip, and feeling rejected by friends. A one-point increase in the sexual behavior stigma scale was associated with a 7% (95% CI: 4%−9%) increased prevalence of severe psychological distress.
After controlling for demographic covariates (i.e., age, income, and sexual identity), there remained a significant association between severe psychological distress and the gender identity stigma scale (adjusted PR[aPR]=1.08, 95% CI: 1.05, 1.12) as well as a significant association with the sexual behavior stigma scale (aPR=1.06, 95% CI: 1.03, 1.09).
Suicidal Ideation
Overall, 226 (59.3%) participants had suicidal ideation in the past year (Table 3). Suicidal ideation was more prevalent among those who had lower income and who identified as bisexual, pansexual, queer, or asexual. Suicidal ideation was associated with most of the gender identity stigma items but in the unadjusted models was most strongly associated with feeling as though family members have made discriminatory remarks, being verbally harassed, and feeling excluded by family. Furthermore, a one-point increase in the gender identity stigma scale was associated with an 11% increased prevalence of suicidal ideation.
Table 3.
Prevalence and correlates of suicidal ideation among US transgender women in the TWIST study, 2019.
| Characteristics | Suicidal Ideation | PR (95% CI) | aPR (95% CI)≠ | |
|---|---|---|---|---|
| Yes n=226 | No n=155 | |||
| Age, n (%) | ||||
| 15–24 | 123 (63.4) | 71 (36.6) | ref | |
| 25–29 | 36 (59.0) | 25 (41.0) | 0.93 (0.74, 1.18) | |
| 30–39 | 26 (59.1) | 18 (40.9) | 0.93 (0.71, 1.22) | |
| 40+ | 41 (50.0) | 41 (50.0) | 0.79 (0.62, 1.00) | |
| Race, n (%) | ||||
| Black, non-Hispanic | 4 (50.0) | 4 (50.0) | 0.88 (0.44, 1.77) | |
| Hispanic | 28 (60.9) | 18 (39.1) | 1.07 (0.83, 1.38) | |
| White, non-Hispanic | 157 (56.9) | 119 (43.1) | ref | |
| Other/multiple races/unknown | 37 (72.5) | 14 (27.5) | 1.28 (1.05, 1.55) | |
| Education Completed, n (%) | ||||
| ≥College | 48 (53.3) | 42 (46.6) | 0.92 (0.73, 1.17) | |
| Some college/AA | 87 (58.0) | 63 (42.0) | ref | |
| HS diploma or less | 83 (62.4) | 50 (37.6) | 1.08 (0.89, 1.30) | |
| Unknown | 8 (100.0) | 0 (0.0) | 1.72 (1.50, 1.98) | |
| Income, n (%) | ||||
| $75,000+ | 24 (46.2) | 28 (53.8) | 0.72 (0.52, 0.99) | |
| $40,000-$74,999 | 34 (52.3) | 31 (47.7) | 0.81 (0.62, 1.06) | |
| $20,000–39,999 | 53 (65.4) | 28 (34.6) | 1.02 (0.83, 1.24) | |
| $0–19,999 | 85 (64.4) | 47 (35.6) | ref | |
| Unknown | 30 (58.8) | 21 (41.2) | 0.91 (0.70, 1.19) | |
| Sexual Identity | ||||
| Gay or homosexual | 30 (53.6) | 26 (46.4) | 0.83 (0.63, 1.09) | |
| Straight or heterosexual | 12 (32.4) | 25 (67.6) | 0.50 (0.31, 0.81) | |
| Bisexual or pansexual | 109 (64.5) | 60 (35.5) | ref | |
| Queer | 41 (60.3) | 27 (39.7) | 0.93 (0.75, 1.17) | |
| Asexual | 5 (83.3) | 1 (16.7) | 1.29 (0.89, 1.88) | |
| Other/unknown | 29 (64.4) | 16 (35.6) | 1.00 (0.78, 1.28) | |
| Region, n (%) | ||||
| West | 65 (64.4) | 36 (35.6) | 1.13 (0.91, 1.39) | |
| Midwest | 43 (58.9) | 30 (41.1) | 1.03 (0.81, 1.32) | |
| Northeast | 50 (56.8) | 38 (43.2) | 0.99 (0.78, 1.26) | |
| South | 68 (57.1) | 51 (42.9) | ref | |
| Urbanicity | ||||
| Rural and small/medium city | 50 (59.5) | 34 (40.5) | ref | |
| Urban and suburban | 176 (59.3) | 121 (40.7) | 1.00 (0.81, 1.22) | |
| Gender Identity Stigma | ||||
| Excluded by family | 182 (64.5) | 100 (35.5) | 1.74 (1.28, 2.35) | 1.62 (1.20, 2.19) |
| Gossiped about by family | 182 (65.0) | 98 (35.0) | 2.11 (1.45, 3.07) | 1.98 (1.36, 2.88) |
| Felt rejected by friends | 162 (67.2) | 79 (32.8) | 1.42 (1.16, 1.74) | 1.38 (1.12, 1.68) |
| Afraid to seek health services | 141 (70.5) | 59 (29.5) | 1.51 (1.25, 1.81) | 1.47 (1.22, 1.76) |
| Avoided health services | 113 (72.0) | 44 (28.0) | 1.43 (1.21, 1.68) | 1.38 (1.17, 1.63) |
| Treated poorly in health facility | 84 (73.0) | 31 (27.0) | 1.41 (1.20, 1.67) | 1.41 (1.19, 1.67) |
| Healthcare workers gossiped | 56 (70.0) | 24 (30.0) | 1.24 (1.03, 1.48) | 1.22 (1.02, 1.46) |
| Did not feel protected by police | 65 (76.5) | 20 (23.5) | 1.42 (1.21, 1.68) | 1.42 (1.20, 1.70) |
| Felt scared in public | 206 (62.8) | 122 (37.2) | 1.57 (1.11, 2.23) | 1.47 (1.04, 2.08) |
| Verbally harassed | 189 (65.6) | 99 (34.4) | 2.05 (1.47, 2.86) | 2.01 (1.45, 2.79) |
| Blackmailed | 42 (77.8) | 12 (22.2) | 1.40 (1.18, 1.67) | 1.37 (1.14, 1.64) |
| Physically hurt | 87 (76.3) | 27 (23.7) | 1.55 (1.31, 1.83) | 1.56 (1.32, 1.86) |
| Forced sex | 48 (81.4) | 11 (18.6) | 1.52 (1.29, 1.80) | 1.47 (1.25, 1.74) |
| Total Scale Score (GI) | - | - | 1.11 (1.08, 1.14) | 1.10 (1.07, 1.13) |
| Sexual Behavior Stigma | ||||
| Excluded by family | 61 (67.0) | 30 (33.0) | 1.19 (0.99, 1.42) | 1.22 (1.02, 1.45) |
| Gossiped about by family | 91 (64.5) | 50 (35.5) | 1.18 (0.99, 1.41) | 1.19 (1.00, 1.42) |
| Felt rejected by friends | 73 (72.3) | 28 (27.7) | 1.35 (1.14, 1.59) | 1.34 (1.14, 1.58) |
| Afraid to seek health services | 36 (73.5) | 13 (26.5) | 1.26 (1.03, 1.53) | 1.21 (0.98, 1.48) |
| Avoided health services | 25 (69.4) | 11 (30.6) | 1.17 (0.92, 1.49) | - |
| Treated poorly in health facility | 26 (78.8) | 7 (21.2) | 1.40 (1.15, 1.71) | 1.35 (1.09, 1.67) |
| Healthcare workers gossiped | 17 (70.8) | 7 (29.2) | 1.23 (0.93, 1.61) | - |
| Did not feel protected by police | 32 (72.7) | 12 (27.3) | 1.26 (1.02, 1.56) | 1.26 (1.01, 1.59) |
| Felt scared in public | 83 (65.9) | 43 (34.1) | 1.19 (1.01, 1.42) | 1.18 (1.00, 1.41) |
| Verbally harassed | 104 (72.2) | 40 (27.8) | 1.42 (1.20, 1.67) | 1.41 (1.19, 1.66) |
| Blackmailed | 27 (77.1) | 8 (22.9) | 1.36 (1.11, 1.66) | 1.33 (1.08, 1.64) |
| Physically hurt | 42 (71.2) | 17 (28.8) | 1.28 (1.06, 1.55) | 1.28 (1.05, 1.56) |
| Forced sex | 28 (82.4) | 7 (20.6) | 1.48 (1.23, 1.79) | 1.42 (1.17, 1.71) |
| Total Scale Score (SB) | - | - | 1.05 (1.03, 1.07) | 1.05 (1.02, 1.07) |
Demographic covariates: income, sexual identity.
Suicidal ideation was similarly associated with most of the sexual behavior stigma items but in unadjusted models was most strongly associated with feeling poorly treated in a health facility, being verbally harassed, and forced sex. A one-point increase in the sexual behavior stigma scale was associated with a 5% increased prevalence in suicidal ideation.
After controlling for demographic covariates (i.e., income, sexual identity), there remained a significant association between suicidal ideation and the gender identity stigma scale (aPR=1.10, 95% CI: 1.07, 1.13), as well as a significant association with the sexual behavior stigma scale (aPR=1.05, 95% CI: 1.02, 1.07).
Suicide Attempt
Overall, 50 (13.12%) participants made a suicide attempt in the past year (Table 4). Suicide attempt was more prevalent among those who were younger or who did not live in an urban/suburban area. In unadjusted models, feeling rejected by friends, feeling unprotected by police, and avoiding health services were most strongly associated with suicide attempt. In addition, a one-point increase in the gender identity stigma scale was associated with a 14% increased prevalence in suicide attempt.
Table 4.
Prevalence and correlates of suicide attempt among US transgender women in the TWIST study, 2019.
| Characteristics | Suicide Attempt | PR (95% CI) | aPR (95% CI)¥ | |
|---|---|---|---|---|
| Yes n=50 | No n=172 | |||
| Age, n (%) | ||||
| 15–24 | 35 (28.7) | 87 (71.3) | ref | |
| 25–29 | 7 (20.0) | 28 (80.0) | 0.70 (0.34, 1.43) | |
| 30–39 | 5 (19.2) | 21 (80.8) | 0.67 (0.29, 1.55) | |
| 40+ | 3 (7.7) | 36 (92.3) | 0.27 (0.09, 0.83) | |
| Race, n (%) | ||||
| Black, non-Hispanic | 3 (75.0) | 1 (25.0) | 3.28 (1.73, 6.20) | |
| Hispanic | 6 (21.4) | 22 (78.6) | 0.94 (0.43, 2.02) | |
| White, non-Hispanic | 35 (22.9) | 118 (77.1) | ref | |
| Other/multiple races/unknown | 6 (16.2) | 31 (83.8) | 0.71 (0.32, 1.56) | |
| Education Completed, n (%) | ||||
| ≥College | 5 (10.9) | 41 (89.1) | 0.53 (0.21 (1.33) | |
| Some college/AA | 18 (20.7) | 69 (79.3) | ref | |
| HS diploma or less | 24 (29.6) | 57 (70.4) | 1.43 (0.84, 2.44) | |
| Unknown | 3 (37.5) | 5 (62.5) | 1.81 (0.68, 4.86) | |
| Income, n (%) | ||||
| $75,000+ | 5 (20.8) | 19 (79.2) | 0.78 (0.33, 1.83) | |
| $40,000-$74,999 | 6 (17.6) | 28 (82.4) | 0.66 (0.29, 1.48) | |
| $20,000–39,999 | 7 (13.5) | 45 (86.5) | 0.50 (0.23, 1.09) | |
| $0–19,999 | 22 (26.8) | 60 (73.2) | ref | |
| Unknown | 10 (33.3) | 20 (66.6) | 1.24 (0.67, 2.31) | |
| Sexual Identity | ||||
| Gay or homosexual | 4 (13.3) | 26 (86.7) | 0.60 (0.23, 1.60) | |
| Straight or heterosexual | 3 (25.0) | 9 (75.0) | 1.13 (0.40, 3.20) | |
| Bisexual or pansexual | 24 (22.2) | 84 (77.8) | ref | |
| Queer | 10 (25.0) | 30 (75.0) | 1.13 (0.59, 2.14) | |
| Asexual | 1 (20.0) | 4 (80.0) | 0.90 (0.15, 5.40) | |
| Other/unknown | 8 (29.6) | 19 (70.4) | 1.33 (0.67, 2.64) | |
| Region, n (%) | ||||
| West | 11 (17.7) | 51 (82.3) | 1.10 (0.51, 2.35) | |
| Midwest | 14 (32.6) | 29 (67.4) | 2.01 (1.01, 4.02) | |
| Northeast | 14 (28.6) | 35 (71.4) | 1.77 (0.88, 3.56) | |
| South | 11 (16.2) | 57 (83.8) | ref | |
| Urbanicity | ||||
| Rural and small/medium city | 17 (34.0) | 33 (66.0) | ref | |
| Urban and suburban | 33 (19.2) | 139 (80.8) | 0.56 (0.34, 0.93) | |
| Gender Identity Stigma | ||||
| Excluded by family | 41 (23.0) | 137 (77.0) | 1.34 (0.57, 3.11) | |
| Gossiped about by family | 43 (24.0) | 136 (76.0) | 1.20 (0.48, 3.00) | - |
| Felt rejected by friends | 42 (26.4) | 117 (73.6) | 2.26 (1.08, 4.77) | 2.44 (1.16, 5.11) |
| Afraid to seek health services | 35 (25.2) | 104 (74.8) | 1.53 (0.86, 2.72) | - |
| Avoided health services | 32 (29.1) | 78 (70.9) | 1.87 (1.10, 3.16) | 1.74 (1.04, 2.91) |
| Treated poorly in health facility | 25 (30.5) | 57 (69.5) | 1.63 (1.00, 2.67) | 2.14 (1.29, 3.56) |
| Healthcare workers gossiped | 15 (27.8) | 39 (72.2) | 1.40 (0.82, 2.39) | - |
| Did not feel protected by police | 23 (36.5) | 40 (63.5) | 2.11 (1.29, 3.46) | 2.40 (1.49, 3.84) |
| Felt scared in public | 47 (23.3) | 155 (76.7) | 1.55 (0.53, 4.55) | - |
| Verbally harassed | 43 (23.1) | 143 (76.9) | 1.16 (0.50, 2.65) | - |
| Blackmailed | 15 (35.7) | 27 (64.3) | 1.85 (1.11, 3.08) | 1.64 (0.98, 2.72) |
| Physically hurt | 21 (24.7) | 64 (75.3) | 1.25 (0.73, 2.11) | - |
| Forced sex | 10 (21.7) | 36 (78.3) | 0.93 (0.50, 1.72) | - |
| Total Scale Score (GI) | - | - | 1.14 (1.04, 1.26) | 1.17 (1.06, 1.29) |
| Sexual Behavior Stigma | ||||
| Excluded by family | 21 (35.0) | 39 (65.0) | 1.97 (1.20, 3.21) | 2.04 (1.29, 3.23) |
| Gossiped about by family | 27 (31.0) | 60 (69.0) | 1.78 (1.06, 2.98) | 1.78 (1.09, 2.90) |
| Felt rejected by friends | 17 (24.3) | 53 (75.7) | 1.17 (0.69, 1.99) | - |
| Afraid to seek health services | 13 (37.1) | 22 (62.9) | 1.95 (1.15, 3.30) | 1.90 (1.15, 3.13) |
| Avoided health services | 9 (37.5) | 15 (62.5) | 1.90 (1.05, 3.44) | 1.93 (1.09, 3.44) |
| Treated poorly in health facility | 11 (44.0) | 14 (56.0) | 2.34 (1.37, 3.99) | 2.70 (1.62, 4.50) |
| Healthcare workers gossiped | 6 (40.0) | 9 (60.0) | 1.98 (1.00, 3.91) | 2.17 (1.14, 4.10) |
| Did not feel protected by police | 11 (36.7) | 19 (63.3) | 1.95 (1.11, 3.43) | 2.21 (1.30, 3.73) |
| Felt scared in public | 21 (26.3) | 59 (73.8) | 1.34 (0.81, 2.22) | - |
| Verbally harassed | 24 (23.5) | 78 (76.5) | 1.20 (0.72, 2.00) | - |
| Blackmailed | 11 (40.7) | 16 (59.3) | 2.13 (1.24, 3.66) | 1.88 (1.06, 3.32) |
| Physically hurt | 11 (27.5) | 29 (72.5) | 1.27 (0.71, 2.28) | - |
| Forced sex | 7 (25.9) | 20 (74.1) | 1.18 (0.58, 2.38) | - |
| Total Scale Score (SP) | - | - | 1.10 (1.03, 1.17) | 1.10 (1.03, 1.17) |
Demographic covariates: age, urbanicity.
In unadjusted models, being treated poorly in a health facility, being blackmailed, and hearing gossip from healthcare workers were most strongly associated with suicide attempt. In addition, a one-point increase in the sexual behavior stigma scale was associated with a 10% increased prevalence in suicide attempt.
After controlling for demographic covariates (i.e. age, urbanicity), there remained a significant association between suicide attempt and the gender identity stigma scale (aPR=1.17, 95% CI: 1.06, 1.29), as well as a significant association with the sexual behavior stigma scale (aPR=1.10, 95% CI: 1.03, 1.17).
DISCUSSION
In comparison with majority cisgender samples in the US (6), our sample of transgender women had disproportionately high rates of severe psychological distress and past-year suicidal ideation and suicide attempts. In adjusted analyses, significant positive associations were observed between the gender identity stigma items and scale with severe psychological distress, suicidal ideation, and suicide attempt. Significant and positive associations were similarly observed between the sexual behavior stigma items and scale with severe psychological distress, suicidal ideation, and suicide attempt. These findings suggest that gender identity stigma and sexual behavior stigma may play different but synergistic roles in increasing the experiences of mental distress among transgender women.
The health care-specific sexual practice stigma items were strongly associations behavior with severe psychological distress, suicidal ideation, and suicide attempts including items measuring having heard health care workers gossip, feeling poorly treated in a health facility, being afraid to seek care, and avoiding seeking care. While previous studies have demonstrated that transgender women may avoid seeking health care and feel discriminated against by health care workers due to transphobia (27–28), this study further suggests that perceived, anticipated, and enacted stigmas related to sexual behavior within the context of health care are also common and strongly related to key mental health outcomes. In one qualitative study, (29) transgender women highlighted the need for informed and respectful sexual health care to avoid exposure to gender binary, cis- and heteronormative expectations that may discourage health care engagement. Gender-affirming and inclusive sexual health programs, on the other hand, may support health care engagement (30–32). The results presented here further support that strategies such as working to consider, assess, and understand diverse sexual behavior among transgender women and transgender people more broadly – may have a positive effect on transgender women’s health care engagement, and, consequently, their mental health.
There are relatively few reports of specific kinds of violence outside of physical assault, sexual assault, or verbal assaults toward transgender women, however, one study (33) found that 2% of transgender women experienced blackmail or extortion. In our study, around one in seven individuals experienced blackmail due to gender identity, and about one in 10 individuals experienced blackmail due to sexual behavior. This form of violence (i.e., blackmail) emerged as having strong associations with severe psychological distress and suicide attempts. In addition, sexual violence was prevalent with 2 in 10 individuals reporting experiencing sexual violence due to gender identity, and 1 in 10 individuals reporting experiencing sexual violence due to sexual behavior. Forced sex due to sexual behavior was associated with both severe psychological distress and suicidal ideation. It is possible that structural stigma in the form of systematic discrimination against transgender persons in health care, housing, and employment contexts could increase opportunities for violence, e.g., blackmail, sexual violence, with no legal recourse (34–35). In addition, community stigma and social norms that oppress and devalue transgender persons, and gender and sexual diversity at large, may produce environments where violence targeting transgender women occurs in communities, families, and intimate partnerships (36).
Prior research has proposed that perceived and anticipated stigmas may serve as barriers to accessing health care, including mental health care, while other studies have found that the perception of stigmas may be higher among individuals who are receiving mental health services that could make them more stigma-aware (36–37). In either case, our results suggest that mental health care that moves beyond non-discrimination efforts and toward care that is informed and intentionally gender identity and sexuality inclusive, non-stigmatizing, and affirming for transgender women to ensure access to, and continued engagement for, individuals who may require mental health services, is needed. Connecting transgender women with both gender identity and sexuality affirming mental health services is key, including needing to engage trans-lead or trans-collaborative community-based organizations for direct outreach efforts through social media campaigns and other services.
The findings of this study should be interpreted considering several limitations. All measures used were self-reported and therefore may be subject to recall and social desirability biases. For example, participants may have underreported severe psychological distress, suicidal ideation, and suicide attempts due to the sensitive nature of these topics. In addition, the data were cross-sectional and therefore we could not provide evidence for temporality or causality in the associations between gender identity and sexual behavior stigmas with severe psychological distress, suicidal ideation, and suicide attempts. Although associations were observed between these variables, the relatively small sample size, impacts the study’s power and potential reproducibility of the results. An additional limitation is that a convenience sample of participants were recruited online was used, which limits the study’s generalizability to transgender women who may have limited internet access or who do not frequent the websites that were used to recruit participants.
Taken together, these results call attention to sustained and harmful associations of both gender identity and sexual behavior stigma with severe psychological distress, suicidal ideation, and suicide attempt among transgender women in the US. While interventions in the US are available, they tend to be focused in select urban centers and access to multilevel interventions that work to address multiple intersecting types related to gender identity and sexual behavior remains limited. Moving forward necessitates continued training for all providers in trans-competent care, as well as the development of newer engagement and delivery approaches for stigma mitigation interventions to address the harmful outcomes of stigma, including sustained mental and sexual health inequities among transgender women across the US.
Source of Funding and Conflicts of Interest
This study was funded by the National Institutes of Health (R01MH110358-02S1 and P30AI050409). Additionally, JM received research support from the National Institute of Allergy and Infectious Diseases (T32AI102623). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors have no conflicts of interest to report.W
Footnotes
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REFERENCES
- 1).James SE, Herman JL, Rankin S, et al. The report of the 2015 U.S. Transgender Survey http://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF. Washington, DC: National Center for Transgender Equality; 2016. Accessed 30 September 2019. [Google Scholar]
- 2).Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press (US); 2011. [PubMed] [Google Scholar]
- 3).Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: The National Gay and Lesbian Task Force and the National Center for Transgender Equality; 2011. [Google Scholar]
- 4).Klemmer CL, Arayasirikul S, Raymond HF. Transphobia-based violence, depression, and anxiety in transgender women: The role of body satisfaction. Journal of Interpersonal Violence. 2018. March 11;00(0):1–23. [DOI] [PubMed] [Google Scholar]
- 5).Yang MF, Manning D, van den Berg JJ, Operario D. Stigmatization and mental health in a diverse sample of transgender women. LGBT Health. 2015. December 1;2(4):306–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6).Bose J, Hedden SL, Lipari RN, Park-Lee E . Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration website. https://store.samhsa.gov/system/files/sma18-5068.pdf. Published September 2018. Accessed 30 September 2019. [Google Scholar]
- 7).Dowshen N, Lee S, Franklin J, Castillo M, Barg F. Access to medical and mental health services across the HIV care continuum among young transgender women: A qualitative study. Transgender Health. 2017. July 1;2(1):81–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8).Budge SL, Adelson JL, Howard KA. Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology. 2013. June;81(3):545. [DOI] [PubMed] [Google Scholar]
- 9).Bazargan M, Galvan F. Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health. 2012. December;12(1):663. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10).Nemoto T, Bödeker B, Iwamoto M. Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work. American Journal of Public Health. 2011. October;101(10):1980–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11).Clements-Nolle K, Guzman R, Harris SG. Sex trade in a male-to-female transgender population: Psychosocial correlates of inconsistent condom use. Sexual Health. 2008. March 19;5(1):49–54. [DOI] [PubMed] [Google Scholar]
- 12).Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality. 2006. October 11;51(3):53–69. [DOI] [PubMed] [Google Scholar]
- 13).Quinlivan EB, Gaynes BN, Lee JS, Heine AD, Shirey K, Edwards M, Modi R, Willig J, Pence BW. Suicidal ideation is associated with limited engagement in HIV care. AIDS and Behavior. 2017. June 1;21(6):1699–708. [DOI] [PubMed] [Google Scholar]
- 14).Glynn TR, Gamarel KE, Kahler CW, Iwamoto M, Operario D, Nemoto T. The role of gender affirmation in psychological well-being among transgender women. Psychology of Sexual Orientation and Gender Diversity. 2016. September;3(3):336. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15).Bose J, Hedden SL, Lipari RN, Park-Lee E. Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf. Published September 2016. Accessed 29 September 2019. [Google Scholar]
- 16).Nuttbrock L, Hwahng S, Bockting W, Rosenblum A, Mason M, Macri M, Becker J. Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research. 2010. January 22;47(1):12–23. [DOI] [PubMed] [Google Scholar]
- 17).Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention. American Journal of Public Health. 2001. June;91(6):915. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18).Bauer GR, Scheim AI, Pyne J, Travers R, Hammond R. Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in Ontario, Canada. BMC Public Health. 2015. December;15(1):525. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19).Gamarel KE, Reisner SL, Laurenceau JP, Nemoto T, Operario D. Gender minority stress, mental health, and relationship quality: A dyadic investigation of transgender women and their cisgender male partners. Journal of Family Psychology. 2014. August;28(4):437. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20).Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin. 2003. September;129(5):674. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21).Logie CH, James L, Tharao W, Loutfy MR. “We don’t exist”: A qualitative study of marginalization experienced by HIV‐ positive lesbian, bisexual, queer and transgender women in Toronto, Canada. Journal of the International AIDS Society. 2012. April;15(2):10–7448. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22).Stahlman S, Grosso A, Ketende S, Sweitzer S, Mothopeng T, Taruberekera N, Nkonyana J, Baral S. Depression and social stigma among MSM in Lesotho: Implications for HIV and sexually transmitted infection prevention. AIDS and Behavior. 2015. August 1;19(8):1460–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23).Stahlman S, Sanchez TH, Sullivan PS, Ketende S, Lyons C, Charurat ME, Drame FM, Diouf D, Ezouatchi R, Kouanda S, Anato S. The prevalence of sexual behavior stigma affecting gay men and other men who have sex with men across Sub-Saharan Africa and in the United States. JMIR Public Health and Surveillance. 2016;2(2):e35. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24).Stahlman S, Grosso A, Ketende S, Pitche V, Kouanda S, Ceesay N, Ouedraogo HG, Ky-Zerbo O, Lougue M, Diouf D, Anato S. Suicidal ideation among MSM in three West African countries: Associations with stigma and social capital. International Journal of Social Psychiatry. 2016. September;62(6):522–31. [DOI] [PubMed] [Google Scholar]
- 25).Cange CW, LeBreton M, Billong S, Saylors K, Tamoufe U, Papworth E, Yomb Y, Baral S. Influence of stigma and homophobia on mental health and on the uptake of HIV/sexually transmissible infection services for Cameroonian men who have sex with men. Sexual Health. 2015. August;12(4):315–21. [DOI] [PubMed] [Google Scholar]
- 26).Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry 2003;60:184–9. [DOI] [PubMed] [Google Scholar]
- 27).Socías ME, Marshall BD, Arístegui I, Romero M, Cahn P, Kerr T, Sued O. Factors associated with healthcare avoidance among transgender women in Argentina. International Journal for Equity in Health. 2014. December;13(1):81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28).Jaffee KD, Shires DA, Stroumsa D. Discrimination and delayed health care among transgender women and men. Medical Care. 2016. November 1;54(11):1010–6. [DOI] [PubMed] [Google Scholar]
- 29).Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM, Boyce M. “I don’t think this is theoretical; this is our lives”: How erasure impacts health care for transgender people. Journal of the Association of Nurses in AIDS Care. 2009. September 1;20(5):348–61. [DOI] [PubMed] [Google Scholar]
- 30).Kosenko K, Rintamaki L, Raney S, Maness K. Transgender patient perceptions of stigma in health care contexts. Medical Care. 2013. September 1;51(9):819–22. [DOI] [PubMed] [Google Scholar]
- 31).Reisner SL, Bradford J, Hopwood R, Gonzalez A, Makadon H, Todisco D, Cavanaugh T, VanDerwarker R, Grasso C, Zaslow S, Boswell SL. Comprehensive transgender healthcare: The gender affirming clinical and public health model of Fenway Health. Journal of Urban Health. 2015. June 1;92(3):584–92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32).Zuzelo PR. Improving nursing care for lesbian, bisexual, and transgender women. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2014. July 1;43(4):520–30. [DOI] [PubMed] [Google Scholar]
- 33).Stotzer RL. Violence against transgender people: A review of United States data. Aggression and Violent Behavior. 2009. May 1;14(3):170–9. [Google Scholar]
- 34).Perez-Brumer A, Hatzenbuehler ML, Oldenburg CE, Bockting W. Individual-and structural-level risk factors for suicide attempts among transgender adults. Behavioral Medicine. 2015. July 3;41(3):164–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35).Raiford JL, Hall GJ, Taylor RD, Bimbi DS, Parsons JT. The role of structural barriers in risky sexual behavior, victimization and readiness to change HIV/STI-related risk behavior among transgender women. AIDS and Behavior. 2016. October 1;20(10):2212–21. [DOI] [PubMed] [Google Scholar]
- 36).Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health. 2013. May;103(5):943–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37).Shipherd JC, Green KE, Abramovitz S. Transgender clients: Identifying and minimizing barriers to mental health treatment. Journal of Gay & Lesbian Mental Health. 2010. March 31;14(2):94–108. [Google Scholar]