Systems of cissexism and the daily production of stress for transgender and gender diverse people

Abstract

Background

Transgender and gender diverse (TGD) people encounter a range of minority stressors (e.g., harassment, victimization, misgendering) that impact many areas of life. Much of the empirical literature on gender minority stress has utilized frameworks that were developed with a focus on sexual orientation and were often limited to cisgender sexual minorities (lesbian, gay, bisexual, and other non-heterosexual individuals), leaving questions about how well existing models fit the experiences of TGD people.

Aims

To expand understandings of gender minority stress, we conducted a daily diary study where participants detailed the types of stressors they encountered on a daily basis for 56 days.

Methods

There were 181 TGD participants recruited into the study (M age = 25.6 years; SD = 5.6), with 167 retained in the daily surveys from which these analyses were conducted.

Results

The written responses revealed a variety of stressors, some of which are novel to the literature. Many participants reported instances of non-affirmation, such as misgendering, as well as vicarious stress when learning of oppressive experiences impacting other TGD people and seeing negative media portrayals of the lives of TGD individuals. Participants also reported bodily vigilance when being on alert for how others were perceiving their gender. Other stressors included rejection, political oppression, physical violence, uneasiness from others, and the enforcement of gender binarism.

Discussion

These findings highlight gaps in the existing understandings of marginalization for TGD people that must be addressed to ensure that frameworks include and center the experiences of gender minorities.

Transgender and gender diverse (TGD) individuals (i.e., people whose gender identity differs from that typically associated with their sex assigned at birth) experience a great amount of social stigma and oppression. As many as three out of four TGD people experienced discrimination in the prior year (Puckett et al., 2020) and 33–53% experienced some form of physical violence in their lifetime (Stotzer, 2009). Research also shows that exposure to these stressors is associated with significant mental health challenges, such as depression, anxiety, and suicidality (Bockting et al., 2013; Puckett et al., 2020; Rood et al., 2015; Staples et al., 2018). Although research has grown substantially in this area, most research has prioritized using models of minority stress that were not developed with TGD people in mind, potentially resulting in oversight of stressors that may be impacting this community. In this study, we describe the daily stressors that TGD people encountered based on written descriptions from an intensive daily diary study in the hopes of expanding understandings of gender minority stress through centering the narratives of TGD people.

Marginalization stress

Minority stress theory was originally proposed to help explain the mental health disparities that are evidenced in lesbian, gay, and bisexual (LGB) individuals that are driven by oppressive experiences related to having a sexual minority identity (Brooks, 1981; Meyer, 2003). Although originally termed “minority stress,” terms like “marginalization stress” may better describe these experiences because it centers the marginalization that minorities experience rather than simply having a minority identity. Distal stressors include experiences of discrimination, violence, or rejection related to one’s sexual orientation, while proximal stressors include expectations of rejection, concealment of one’s sexual orientation, and internalized heterosexism (Meyer, 1995, 2003). Distress associated with both distal and proximal stressors include higher rates of depressive symptoms, anxiety symptoms, and substance abuse (Igartua et al., 2003; Mays & Cochran, 2001; Ullrich et al., 2003).

Although the minority stress model did not originally include TGD individuals, others have examined these constructs in the lives of TGD people and found that most of these stressors are similarly associated with distress in this population. For instance, social stigma has been positively associated with psychological distress (Bockting et al., 2013), gender-based discrimination and victimization have been independently associated with attempted suicide (Clements-Nolle et al., 2006), past year gender related discrimination has been associated with depression and anxiety (Puckett et al., 2020), and physical and sexual violence are related to history of suicide attempts, multiple suicide attempts, alcohol abuse, and illicit substance use (Clements-Nolle et al., 2006; Testa et al., 2012). These associations between marginalization stress and mental health make it clear that this area needs further study. For future research to best serve TGD individuals though, marginalization stress frameworks need to be better tailored to the lives of TGD people.

Reconceptualizing marginalization stress for TGD people

Understandings of marginalization stress need to be adapted to ensure a better fit to the lived experiences of TGD people (Hendricks & Testa, 2012; Puckett, 2019; Puckett et al., 2018; Rood et al., 2017; Testa et al., 2015). For instance, there are unique forms of enacted stigma that TGD people are faced with, such as denial of access to gendered spaces, including restrooms (Testa et al., 2015), or misgendering (DuBois, 2012; McLemore, 2018). At the proximal level, research demonstrates that expectations of rejection may uniquely fluctuate for TGD people according to how readily they believe other people perceive them as being transgender (Rood et al., 2016). These perceptions of gender also are inherently connected to gendered social systems and contexts. For instance, gendered spaces, forms that ask about gender or name, and interactions that require use of identification documents may all uniquely influence expectations of rejection for TGD people. Finally, identity concealment may mean that a TGD person has not come out to others and affirmed their identity or it could mean that a TGD person is not readily perceived by others as being transgender and is faced with disclosing aspects of their transition history (Rood et al., 2017). In fact, although framed as a “stressor,” some TGD individuals report that not revealing to others their transition history is an act of affirmation of their identities and that the disclosure of this would be a stressor—the opposite of many conceptualizations of “identity concealment” as marginalization stress (Rood et al., 2017). There also are additional unique forms of proximal stressors not captured in marginalization stress theory, such as transitioning identity stress, which refers to being in a state of change related to how others know or perceive one’s gender (DuBois et al., 2017).

These unique considerations require us to revisit the concept of marginalization stress and how it may apply to the lives of TGD people. The work of Testa and colleagues (Hendricks & Testa, 2012; Testa et al., 2015) has played a central role in specifying this model to TGD people and developing the Gender Minority Stress and Resilience (GMSR) measure to better reflect some of the lived experiences of this community. Briefly, findings from the GMSR model have shown that distal stress factors, such as gender-related discrimination, rejection, victimization, and non-affirmation have a positive relationship with the proximal stress factors of internalized cissexism, negative expectations for future events, and identity concealment (Testa et al., 2015). Distal and proximal stress factors are correlated with worse mental health, including symptoms of depression and anxiety (Testa et al., 2015). Although the GMSR model confirms and expands understandings of marginalization stress to better capture the experiences of TGD people, it is possible that some experiences may still be overlooked given that this framework relies heavily on sexual minority stressors. To identify such types of unique stressors, research is needed in which TGD people can describe the types of marginalization that they, themselves, faced.

It is also useful to consider how other frameworks about stigma, such as the pivotal work by Herek (2007, 2016), can aid in identifying TGD specific minority stressors. In line with his conceptual framework for stigma that sexual minorities experience, which may generalize to TGD individuals (Herek, 2016), there are four levels at which stigma may manifest (Herek, 2007; Herek et al., 2009): structural and cultural stigma, enacted stigma, felt stigma, and internalized stigma. Structural and cultural stigma refers to the ways in which marginalization of TGD people is built into societies and the institutional factors and cultural values that uphold this marginalization. Enacted stigma refers to overt and behavioral expressions of stigmatizing views. Felt stigma refers to the shared knowledge that a group is devalued and the expectations of mistreatment. And, finally, internalized stigma refers to integrating these negative views of the devalued group into one’s own viewpoints. In identifying novel TGD specific stressors, this conceptual framework can provide a lens for interpreting individual types of stressors as socially embedded phenomena that are always connected to systems of oppression.

Current study

TGD people report a variety of stressors that have a negative toll on their mental health and well-being, yet these stressors are not adequately represented within existing models of marginalization stress. To enhance the framework of marginalization stress, narratives of TGD people need to be prioritized and centered to guide the process of detailing what stressors arise for this community. As such, this study addressed a notable gap in the existing literature—using intensive data collection methods to learn what stressors arise for TGD people in their own words. Data collection in this novel daily diary study spanned 56 daily surveys and the analysis focuses on participants’ written responses about what stressors they personally experienced, providing key insights into the daily lives of these participants.

Method

Participants

The full sample included 181 TGD people who took part in any aspect of the study, including 88 trans men, 34 trans women, 17 genderqueer individuals, and 42 non-binary individuals. Ages ranged from 16 to 40 (M age = 25.6 years; SD = 5.6). Approximately 41% of the sample had an income below $10,000 per year. Most of the sample, 85.1%, were white. Table 1 provides a full overview of the sample demographics.

Table 1.

Sample demographics.

Characteristic	N (%)
Gender identity
Transgender man	88 (48.6%)
Transgender woman	34 (18.8%)
Genderqueer	17 (9.4%)
Non-binary	42 (23.2%)
Sexual orientation
Queer	78 (43.1%)
Pansexual	37 (20.4%)
Bisexual	33 (18.2%)
Gay	11 (6.1%)
Asexual	1 (0.6%)
Heterosexual	10 (5.5%)
Lesbian	8 (4.4%)
Option not listed	3 (1.7%)
Race/Ethnicity
White	154 (85.1%)
Black/African American	3 (1.7%)
American Indian or Alaska Native	1 (0.6%)
Native Hawaiian or other Pacific Islander	0
Asian	0
Latino/a	3 (1.7%)
Option not listed	4 (2.2%)
Multiracial/Multiethnic	16 (8.9%)
Education
Less than high school diploma	5 (2.8%)
High school graduate or equivalent	21 (11.6%)
Some college, but have not graduated	60 (33.1%)
Associates degree or technical school degree	11 (6.1%)
Bachelor’s degree	62 (34.3%)
Master’s degree	13 (7.2%)
Doctorate or professional degree	9 (5%)
Income
Less than $10,000	75 (41.4%)
$10–19,999	43 (23.8%)
$20–29,999	19 (10.5%)
$30–39,999	17 (9.4%)
$40–49,999	10 (5.5%)
$50–69,999	5 (2.8%)
$70–99,999	8 (4.4%)
Over $100,000	3 (1.7%)

Note. 1 participant did not report their income.

Procedures

The overarching aims of this study were to understand the associations between marginalization stress, substance use, mental health, and HIV risk behaviors, as well as the underlying mechanisms that help to explain these associations in TGD individuals. In this daily diary study, participants first completed a screener questionnaire to assess whether they qualified for the daily diary study and, if so, they were enrolled. Participants who qualified were first sent a baseline survey that took approximately 20 minutes to complete. After this, they were sent daily surveys for 56 days, or 8 weeks, to capture experiences that may be infrequent or not occur daily, such as sexual activities. These daily surveys included questions regarding mood, substance use, minority stress, sexual behaviors, and other variables. On the seventh day, participants received the same daily questions, as well as a few more extensive measures that reflected on the past week’s experiences (e.g., mental health). Finally, after 56 days, participants received a brief survey that repeated some of the baseline questions to assess change in experiences such as expectations of encountering discrimination and stigma. We administered the daily surveys for 56 days in order to provide adequate time to capture behaviors that may not be frequent, such as sexual activity, while balancing participant burden.

Inclusion criteria for the daily diary study were: ages 16 to 40 years old; identification as a trans man, trans woman, genderqueer, or non-binary individual; living in the United States; had sex in the past 30 days; and either used substances or binge drank in the past 30 days. These inclusion criteria were established given that we were interested in examining substance use and sexual behaviors and needed to ensure that these were applicable to the participants enrolled in the study. This age range was chosen given that individuals of these ages are those most likely to receive an HIV diagnosis compared to older groups (Centers for Disease Control & Prevention, 2020). Given the inclusion criteria, many individuals were not eligible to participate in the study. Anyone who was not eligible for the daily diaries was offered the chance to participate in a one-time, brief survey about marginalization stress, mental health, and related variables, as long as they were TGD identified, at least 16 years old, and lived in the United States. The findings presented in this manuscript are specifically from participants in the daily diary study and not the one-time survey.

We used a multi-pronged approach to recruitment, including (1) advertisements distributed online via various social media outlets (e.g., Facebook, Twitter, Tumblr); (2) electronic flyers sent to community organizations who worked with TGD individuals; and (3) in-person recruitment at community events. This study was approved by the Institutional Review Board of the primary investigator’s institutions, with a waiver of parental permission for participants who were 16–17 years old. Participants were paid $50–60 (range reflects additional funding that was acquired) for completing at least 85% of the surveys and $20 if they completed less than this but at least 50% of the surveys.

Given that this study was conducted online, several steps were taken to ensure the quality of the data collection. These steps included: completion of a screener questionnaire prior to gaining access to the study; reviewing all email addresses to identify duplicate or suspicious responses; reviewing IP addresses for duplicate responses; using a link for baseline, daily, and final surveys that was unique to each individual enrolled in the study; utilizing survey protection options on the survey platforms that prevented the study and screener from being completed by the same individual multiple times; including a CAPTCHA to inhibit programmed responses; and including three questions to assess participants’ understanding of the study and consent information (participants had to answer these correctly to be included in the study). Finally, for participants who were enrolled in the daily diary study, their initial screener responses were compared to their baseline responses in terms of key demographics (e.g., age, race, gender, sex assigned at birth) and individuals with inconsistent responses were removed from the data.

A community advisory board (CAB) was an essential element of the project. The board consisted of a small group of TGD individuals who met weekly for a month prior to the launch of the study to discuss the aims, surveys, recruitment materials and strategies, and other important aspects. The CAB met periodically during data collection and for a brief period after the study ended to discuss issues with recruitment and retention, sensitivity to the lived experiences of TGD people, and preliminary interpretation of findings. The lead researcher also identifies as TGD and all authors have expertise and a background in research with TGD communities.

After cleaning the data, there were 181 participants who enrolled in this daily diary study. There were 177 participants (97.8%) who continued on in the daily survey portion of the study after completing the baseline survey. There were 145 participants (80.1%) who completed the final follow-up survey at the end of the 8 weeks. Of the 177 participants who started the daily surveys, participants who reported less than a week’s worth of data were removed given that these responses may not have been representative of the sample, resulting in 167 participants with daily survey data. Across the 167 participants with daily survey data, there were 7,436 entries out of the 9,352 possible daily observations, meaning that there was a completion rate of 79.5% for the daily surveys. The number of missing daily entries per participant ranged from 0 to 47 days.

Measures

Demographics

Participants completed questions about their age, gender, sexual orientation, race/ethnicity, income, employment, and education. These were asked as a questionnaire and the response options are available in Table 1.

Marginalization stress

Participants provided written responses about stressors they experienced that were not reflected in a checklist of types of marginalization and were asked to describe these stressors on a daily basis. For context of understanding the written responses, an overview of the checklist is provided. This checklist was created by the research team based on a review of the existing literature about common stressors that TGD people experience and existing scales of marginalization stress for LGBTQ people given that measurement development in this area has been limited. The CAB reviewed the checklist and offered suggestions for items that were added. This resulted in a final list of 15 items on the checklist (see Table 2), with an additional option to indicate that participants did not experience any of these events.

Table 2.

Checklist of marginalization stress utilized in quantitative data collection.

Verbally insulted or threatened

Physical violence, like being punched or beaten

Attacked sexually

Someone threatened to tell others you are transgender or outed you as transgender

Someone made sexual advances toward you in a way that was fetishizing

Someone asked you invasive questions related to your gender identity and/or body

Others did not respect your privacy regarding your trans identity

Discriminated against in some way

Someone used transphobic language or slurs

Someone stereotyped or made assumptions about you or someone else related to being trans

Someone questioned the legitimacy of your gender identity or transition history

Other people acted as if they were uncomfortable with you (e.g., someone stared at you or was whispering about you)

Others minimized that transphobia/stigma toward people who are trans or gender nonconforming exists (e.g., said that you or someone else was overreacting or being defensive)

Felt like others disrespected you or were judging you because you’re not cisgender

Felt like other people were monitoring your behavior because of their expectations for your gender

Given that this is an emerging area of research, participants were asked to indicate (yes or no) if there was something else that they experienced that was not captured in the checklist (prompt: “Were there any other experiences where you felt like you were treated differently or where you felt like you encountered stigma related to being trans or gender nonconforming?”). If participants responded “yes” they were provided with a textbox to elaborate on this experience. Analyses in this study focused specifically on the open-ended responses to this item and not on the checklist. The checklist is described simply for context of understanding the written responses from participants.

Analyses

Descriptive statistics and frequencies regarding sample demographics were conducted in SPSS. For the qualitative data, a thematic analysis was conducted (Braun & Clarke, 2012) wherein the first author reviewed all of the data to identify common experiences that participants reported, developed a list of codes that represented these common themes in the data along with definitions of each theme, and then applied the codes to participant responses using NVivo qualitative data analysis software. After all of the data was coded, the first author conducted a review of each of the themes to ensure that the data included in each theme was consistent with the definition of the code while making small adjustments as needed to ensure consistency in coding. To ensure methodological integrity during the coding process (Levitt et al., 2018), the following steps were taken: (1) the creation of a codebook with specific definitions for what data should be included in each theme; (2) memoing by the first author to reflect on the process; (3) an auditing of each theme at the end of the coding to verify that data included in each theme indeed reflected that theme; and (4) providing quotes to exemplify each theme.

Results

Over the course of the 56 days, 69.6% of the sample indicated that they experienced marginalization stress not described in our checklist. Across all participants and all days, there were a total of 446 written responses, which were provided by 116 (69.6%) of the 167 participants retained in the daily surveys. Of the participants who provided responses, these ranged from 1 to 22 responses over the 56 days (M = 4 responses).

Here we describe the themes that emerged from the written responses and quotes are provided that characterized each theme. These themes are situated within Herek’s (2007, 2016) conceptual framework across the levels of structural and cultural stigma, enacted stigma, and felt stigma. Due to the wording of the prompt, there were not many responses that aligned with internalized stigma and therefore this was not included in our theme organization (this data was instead included in other themes). In addition, there were some themes that were present in the data, but not common. These were grouped into a category of “infrequent themes.” Table 3 includes a list of the themes and the levels of Herek’s conceptual framework that each aligns with.

Table 3.

Themes from qualitative data.

Structural and cultural

Political oppression

Gender binarism

Enacted stigma

Violence and harassment

Non-affirmation of TGD identity

Body/Gender policing

Experiences of rejection

Negative experiences in medical care or related to insurance

Negative experiences in sex and intimate relationships

Felt stigma

Bodily vigilance

Vicarious stress exposure

Perceived uneasiness from others

Infrequent themes

Minimization of transphobia

Personal discomfort with one’s body

Invasive questions

Outed to other people as TGD

Note. TGD = transgender and gender diverse.

Structural and cultural stigma

At the structural and cultural levels, TGD people in the United States are subjected to having their rights up for political debate, with many attempts to institutionalize the oppression of this marginalized community. These experiences also manifested in the reflections of this study’s participants. Political oppression was defined as descriptions of political events, legislation, laws, or other systemic issues. Several responses were related to the 2016 presidential election and Trump himself. For instance, participants mentioned specific policies by the Trump administration (e.g., “trans military ban progress announced.”) or the atmosphere that participants felt surrounded the election (e.g., “I was in DC during the inauguration and felt singled out and unsafe around the vast numbers of Trump supporters due to my identity.”). Responses in this category also included people who were exposed to oppressive comments from others related to the election, such as this participant: “People are telling me and other gender non conforming people not to be upset or fearful and even how to feel about the election results and it is always cis white people who say it.” Responses about the 2016 election have been more detailed in Price et al. (2020). There were other responses that were specific to states and anti-TGD legislation that had either been proposed or passed.

Another theme that reflected the broader discourse about TGD people was that of gender binarism, which related to having one’s gender invalidated, unacknowledged, or questioned by others explicitly due to existing in a society where a binary understanding of gender is imposed on all. For instance, participants reported trouble shopping for clothing (e.g., “I had to go shopping for sports bras, and I looked like a guy shopping for women’s clothes and got stares and people looking uncomfortable with my presence in that part of the store.”) and when accessing public restrooms (e.g., “When entering the men’s bathroom, a worker stopped me and pointed me in the direction of the women’s bathroom. Upon walking in, a woman occupying the restroom audibly gasped and said ‘excuse me sir?’ I apologized and left.”). Other participants reported interpersonal slights that were built upon binary understandings of gender, such as the following: “Talking about gender-reveal parties, my identity was invalidated.” Although these experiences often also reflected specific behavioral manifestations of stigma (or, enacted stigma), they also were rooted in binary understandings of gender that structured the social environment.

Enacted stigma

Although the checklist included items about physical violence and other forms of enacted stigma, participants also reported these incidents in their written responses. Within this theme, there were descriptions of violence and harassment, such as this participant’s response: “Corrected pronoun in bar. Was told it didn’t matter, i was being overly sensitive. Then followed outside and called me a bitch repeatedly.” Other participants mentioned damage to physical property, such as:

Recently I was on the local news and talked about the struggles of being transgender. Yesterday while I was at the store someone removed the lug nuts from my tire, when I went to leave the tire fell off my truck damaging it. The sheriff that responded to the call said it was probably a hate crime due to my TV appearance.

The most frequently endorsed theme in the data was non-affirmation, which referred to actions or mistreatment that referenced TGD people in ways that differ from or negate their current gender identity. Non-affirmation included acts of being misgendered by people who were strangers and thus may not have known participants’ chosen names or pronouns, as well as individuals who knew participants and were aware of this information but either intentionally or unintentionally did not use affirming language to reference them. Non-affirmation included others using the wrong pronouns (e.g., “My parents do try, but still have some pronoun trouble, even after two years.”), using a person’s given name (e.g., “Doctor misgendered me and called me by my birth name even though it’s on my file and I was there to get my testosterone shot.”), and using gendered language (e.g., “The part-time accountant who I’ve been working with for a year and a half sent an email to my boss and I that started, Hi Ladies”).

Non-affirmation also occurred through interpersonal mannerisms or behaviors, such as enforcement of gender binaries and inaccurately categorizing participants in these binary understandings of gender, such as this participant: “Got a haircut. The hairdresser was very awkward and was like ‘sorry i’m going to have to charge you the women’s price…’.” Non-affirmation also occurred when others assumed that participants were cisgender (e.g., “people think i’m cis on the days in which i present more femininely and it sucks and feels really invalidating”). Interpersonal interactions were also a source of non-affirmation when friends or others made statements that conveyed a lack of acknowledgement of participants’ gender identities (e.g., “My friends are great but sometimes they don’t realize what they say. They were saying it’s nice of my (100% gay) bf to be ok with how I am. He’s not nice for being attracted to me it’s just how he is.”). Similarly, interpersonal interactions are commonly shaped or influenced by how a person’s gender is read or perceived by others and situations such as the following conveyed non-affirmation of participants’ gender identities:

I was saving seats at a basketball game for some friends who went to the bathroom. A group of people tried to sit in their seats, and I told them that they were taken. They didn’t listen to me when I told them twice, so a friend of mine who is a cis man told them the spots were taken and they moved immediately. It made me feel like I wasn’t even remotely passing as a man.

These acts of non-affirmation were fairly common in the sample and at times were intentional and used to directly harm participants (e.g., “The man I almost slept with purposefully used incorrect pronouns while I was performing oral sex on him. He refused to apologize.”).

Another form of enacted stigma reported by participants was body/gender policing, which refers to instances in which others try to enforce gendered expectations onto participants related to their body or gender identity. Participants reported a range of experiences in which other people were seemingly evaluating their gender expression or gender in ways that felt uncomfortable or restrictive. For instance, one participant reported that: “I was unable to use a spa facility to help ease my back pain. They advertised as co-ed, but when I arrived I was told I would not be allowed to wear a swim suit in the men’s area.” This category also included instances where participants’ gender identities were being outright refused by others related to the way they were expressing their gender, such as “I was dressed especially effeminately and people accused me of lying about being trans because of it.” This body/gender policing was also reinforced by institutional policies and practices, such as regulations about identification documents for this participant:

ID check ordeal. Two forms not enough as long as my license is still boy name and picture. Seems like a way for the ID checker to tell everyone ‘hey look: a trans woman!’ while pretending they just [can’t] be sure that I am old enough for a beer (at my 29th birthday party).

This policing frequently happened in gendered spaces, such as restrooms: “I feel like I’m being watched every time I go to the restroom at work.” These acts were often accompanied by invasive questions or invasion of personal space (e.g., “My god father tugged my beard and asked if it was real because he was just so shocked i could grow one.”).

Some participants wrote specifically about experiences of rejection, which were defined as any reports of being socially excluded or having relationships end. This rejection was experienced across various social circles, including family, friends, colleagues, and at school. For instance, one participant reported that: “I was not allowed to be part of my good friend’s wedding party because her new husband doesn’t like that I am trans.” Another participant also recounted an incident of self-focused rejection, “I don’t know if my own internalized stigma/self hate counts, but I did break down and self harm because of hating my nonbinary identity. Most harm comes to me from within, although I learned to hate myself from others.” Overall, this theme revolved around feeling othered and separated from meaningful social connections due to bias against TGD individuals.

Some participants reported negative experiences in medical care or related to their insurance. Participants reported experiences such as medical providers making assumptions about their experience as a TGD person (e.g., “expectation of medical transition”), having exclusions in their health insurance coverage that inflated costs of healthcare (e.g., “Had to get my prescription for testosterone filled yesterday, and payed a fortune out of pocket because my health insurance excludes all treatment related to my transgender status.”), having their TGD identity over-emphasized by medical providers (e.g., “Healthcare seems more focused on my transness than my actual health.”), and being misgendered by medical providers (e.g., “Had to go to walk in clinic with my doctor and her nurse kept referring to me as him, or it even after she check my chart which shows my gender identity disorder.”). These experiences at times overlapped with other themes, such as non-affirmation of TGD identity, but were specific to the medical establishment and thus warranted their own category given the uniqueness of this setting in the lives of TGD people.

Participants also reported negative experiences in sex and intimate relationships. These experiences ranged from challenges in finding partners [e.g., “Online dating (very few people are interested in me, and I know it’s likely not all about being trans/nonbinary, but I do think it has something to do with it)”] to being asked problematic and invasive questions, such as this response:

Influx of messages on Grindr asking invasive questions about my body—"do you still have lady parts" "can i see your bottom half" etc etc as first messages instead of greetings etc. It’s grindr, but it feels like i’m getting screened for others’ sexual [preferences] before even being treated as a person.

Other participants mentioned issues with existing romantic partners, such as:

While my girlfriend is very supportive of my transition, sometimes she says things like "I don’t know if I’ll be attracted to you if you have facial hair" or "look at those lesbians, remember when we used to be lesbians? Yeah those were good times." I [know] she loves me and is very serious about our relationship, just things like that make me very upset.

Felt stigma

Some themes conveyed psychosocial byproducts of stigma, manifesting as felt stigma or the awareness of one’s stigmatized identity and expectations of mistreatment. One theme that aligned to this was bodily vigilance, which referred to participants feeling on alert for how other people were reading their gender expression or what gender other people were perceiving them to be. This experience happened often in public when around strangers and appeared to be heightened by others staring at participants or making comments that conveyed to participants that they did not view their gender as they did. Bodily vigilance was accompanied by feelings of anxiousness, worry about others’ reactions, and intense self-monitoring of participants’ appearance, mannerisms, and speech. This participant’s description exemplifies the ways that bodily vigilance may be experienced: “Yesterday I was feeling dyphoric and uncomfortable in my body, how my clothes looked on me, etc. Feeling this way I think can make me hyper aware of how [others] may be perceiving me.”

Another form of felt stigma, which also happened to be the second most common theme in the data, was vicarious stress. This refers to the emotional toll of exposure to stress narratives from other TGD people or social representations of TGD people. Participants reported witnessing a variety of other individuals experience marginalization, including significant others (e.g., “Although I was not the target here, one stranger aggressively misgendered my girlfriend today–we are on vacation, staying in a hostel, and have definitely felt more exposed to uncomfortable scrutiny than at home.”), friends or peers (e.g., “At trans support group meeting, stories of transphobic encounters from nearly everyone.”), and even strangers (e.g., “Neighbors made transphobic jokes directed at another person.”).

These experiences of vicarious stress were sometimes tied to broader issues of marginalization within the context participants were living in. This was exemplified by the following participant:

The senate [in] my state is currently trying to pass 6 anti-trans bills that would limit my ability to use public restrooms among other things. I feel very angry. Many of my friends are cis and unaware [and] unconcerned this is happening. I’m hearing/reading a lot of ignorance about trans people as I go through my day related to these bills and similar ones across the country.

Furthermore, these experiences were shaped by the broader culture and news surrounding the lives of TGD people, such as this participant’s experience: “People saying ignorant things regarding Caitlyn Jenner on Facebook.” News stories also exposed participants to vicarious stress, such as the high number of transgender people murdered, particularly trans women of color (e.g., “Read about a trans woman being murdered”). In addition, vicarious stress happened both in-person (e.g., “A trans friend had 2 women stop and point at her and yell ‘what is that?’”) and online (e.g., “Seeing Youtube videos in my recommended section attacking trans Youtubers.”).

Finally, participants also reported perceived uneasiness from other people. This stressor included other people staring at participants, whispering and pointing at them, avoiding participants, or even taking pictures of them. Other times participants reported other people speaking or acting in ways that were perceived as “rude” or uncomfortable. For instance, one participant reported, “In my uber ride, the driver was really rude to me throughout and I really can’t know why, but being nonbinary, gender non-conforming and brown, I can’t help but wonder if those identities may be [why].” The incidents in which participants described other people acting uneasy with them ranged from ambiguous situations, such as this participant’s experience: “People stare so long at my beard. Some folks look away when I notice and some make faces,” to more overt acts, such as this participant’s response: “protective parents pulling their kids away.” These were behaviors that conveyed to participants their position in a devalued group and contributed to felt stigma.

Infrequent themes

There were a few other themes that were infrequently endorsed by participants, but are important to note given the emerging nature of this research. These themes included the minimization of transphobia (e.g., “trans issues ignored or glided over”), personal discomfort with one’s body (e.g., “Being uncomfortable with my body”), invasive questions (e.g., “A recent acquaintance asked my friend if I was trans and went on to ask about what genitals I had. When she was asked to stop, she justified her line of questioning by listing her trans friends. My friend later told me this had happened.”), and being outed to other people (e.g., “One very insistent lesbian making sure to out me to everyone, I guess in her mind to raise visibility and awareness?”).

Discussion

The findings from this study show that TGD people find themselves living in contexts that enforce gender norms in oppressive and marginalizing ways, producing stress across many facets of daily life. The themes of political oppression and gender binarism describe these contexts and the social norms that are not only imposed upon TGD people, but that are deeply embedded within legislation, policies, and the organization of social settings and structures (for a more in-depth analysis of data related to political oppression, see Price et al., 2020). For instance, many of the other stressors, like body/gender policing, non-affirmation, and bodily vigilance are either created by or reinforced by binary settings (e.g., restrooms), cissexist policies (e.g., legislation restricting the rights of TGD people), and marginalizing practices that may stem from laws (e.g., checking a person’s ID for alcohol and interrogating them about their identity). This context also results in internalized binary gender beliefs for cisgender people that may lead to many of the acts of non-affirmation reported by participants. As such, we see that the structural and cultural stigma against TGD people shapes the subsequent individual manifestations of stigma (Herek, 2007, 2016).

The consequences of living within this marginalizing context were vast and many types of daily stressors were identified. The most reported form of marginalization stress was non-affirmation. This stressor occurred in many contexts, such as with family, strangers, and coworkers, and included more acts than simply using the incorrect pronoun or name for a person. Non-affirmation also included interpersonal mannerisms and styles of interaction with others. Other research clearly highlights the mental health toll of non-affirmation (McLemore, 2018; Testa et al., 2015). As such, a model of gender-based marginalization stress may need to be adapted to better reflect the range of situations and experiences where this stressor may arise.

Vicarious stress highlights the complicated balance between visibility and stress. As many participants reported, with a rise in media attention to TGD people, they found themselves often hearing of the murders of other TGD people (particularly TGD people of color) or witnessing cissexist remarks when other TGD people were made visible, like the coming out and publicity of Caitlyn Jenner. Participants also found themselves engaged in the emotional labor of holding space for the painful experiences of other community members who were experiencing violence or rejection. This was in addition to participants’ own reports of physical violence, having others reject them, and challenges in medical care settings. As such, many TGD people may find themselves overly taxed with their own direct experiences of marginalization stress, as well as vicarious stress.

TGD people in this sample were also left on high alert for marginalization, seen in the stressor of bodily vigilance. This sense of alertness was often described as being in response to the body/gender policing behaviors of others (that, again, are embedded within social structures that enforce these behaviors) and displays of uneasiness around the participants. The anxiety and intense self-monitoring that TGD people endure to protect themselves from harm can be exhausting to mental energy. In addition, the uneasiness displayed by others that many TGD people experience communicates a rejection from society (e.g., whispering, staring, taking pictures of TGD people), which amplifies feelings of being on edge.

Marginalization stress has been routinely associated with negative mental health outcomes for TGD communities (Bockting et al., 2013; Puckett et al., 2020; Rood et al., 2015) and the current study provides additional information about how challenging and pervasive this stress can be. This is one of the first studies with TGD people specifically that has utilized a daily diary format over an extensive period of two months, providing novel insights into stress that arises daily for TDG people. Several common areas of marginalization stress emerged consistent with the current gender minority stress model including non-affirmation, rejection, and victimization (Hendricks & Testa, 2012; Testa et al., 2015). Despite this, there were many types of marginalization stress that are not reflected in existing frameworks, such as bodily vigilance, vicarious stress, and body/gender policing. Furthermore, a large portion of the sample did not see their stressors reported on the checklist that was provided to them. As such, TGD people may not see their experiences reflected in such checklists and there is a need for measure development specific to this community (Shulman et al., 2017).

Our findings here support the need for a marginalization stress model that centers the voices of TGD people, echoing the calls of other research. For example, Rood and colleagues (2017) found that concealment of gender identity is not always a maladaptive process—for some, concealment is understood as concealment of their assigned sex at birth, physical body, and/or gender history that can be driven by safety concerns or acts of affirmation. In their sample, indeed some participants found concealment to be an affirming experience rather than a stigmatizing one. Ultimately, without prioritizing the narratives of TGD people, such models will never truly reflect TGD peoples’ experiences of marginalization. In extending these models, drawing on Herek’s (2007, 2016) conceptual framework can provide a useful lens for identifying and describing such stressors.

These findings also are relevant to clinical work with TGD populations. Many therapists are cisgender and may not know of the daily hassles, microaggressions, and overt acts of bias that TGD people face. A lack of awareness and education about these experiences may result in misinterpretations or misattributing feelings of anxiety, nervousness, or other emotional processes to an underlying mental health condition rather than placing the source of this emotional distress within the problematic and oppressive social system in which TGD people are living. For instance, a client may feel on edge and guarded about how others view their gender (bodily vigilance) and this could be misinterpreted as paranoia or other pathological processes. Findings from this study may help clinicians to learn to listen to, and hear, their TGD clients when they share information about their daily lives from a more inclusive and culturally responsive stance. This information may also help healthcare providers, policy makers, and organization leaders to more fully understand the lived experiences of TGD people.

Limitations

Although this study is notable for the novel use of daily diary methods and intensive data collection that enabled a unique analysis with a very large dataset of over 400 written responses, there also were important limitations to consider. First, individuals who reported some engagement in sexual activity and binge drinking or substance use in the 30 days preceding their completion of the screener were specifically recruited. This may have biased the sample and precluded the generalization of these findings to individuals who were outside of the recruitment criteria. For instance, it is possible that individuals in the study experienced unique forms of stress or related to stressful experiences in novel ways, such as coping via internalization or substance use. That said, we do know from other research that marginalization stress is extremely common for TGD people (James et al., 2016). As such, it is likely that many of these stressors may manifest in the lives of TGD people more broadly.

Also, the sample was significantly limited in racial and ethnic diversity. Although we cannot be certain of the reason for this, it is possible that the use of online recruitment limited the inclusion of racial and ethnic minorities. It is possible that in-person recruitment and providing alternative ways of participating, such as via text responses, may assist future research in better representing the experiences of TGD people of color. We know from other research (James et al., 2016) that TGD people of color disproportionately experience violence and other forms of marginalization stress compared to white TGD people. As such, future research is needed to better understand whether there are additional stressors that may arise for TGD people of color and whether the stressors that were the most frequent in this sample would be the most common in a more racially and ethnically diverse sample. Such research should also make sure their assessment of race and ethnicity allows for participants to fully describe their identities, which may be limited with demographic questions such as those used in this study. The current study’s sample was also limited to individuals who identified as genderqueer, nonbinary, trans men, or trans women and we cannot be sure whether the findings would be different in other gender subgroups. The demographic questions also had some limitations, such as not assessing disability status.

Future directions and conclusions

This study extends the broader literature examining the impact marginalization stressors have on TGD communities. Results of the present study underscore the importance of addressing gaps in current frameworks of marginalization stress for TGD people. Although it would be impossible to include all experiences of marginalization stress when creating a model and subsequent measures, further development and refinement is necessary. Specifically, broader conceptualization and measurement of non-affirmation and inclusion of other distal and proximal stressors would provide a more robust and accurate representation of TGD communities’ experiences. Finally, these results also emphasize the importance of clinicians considering marginalization stress beyond those identified in current conceptualizations in order to best meet the needs of their clients.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Funding Statement

The project described herein was supported by a grant from the National Institute on Drug Abuse (1F32DA038557; PI: J. Puckett).

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.