Transgender and Gender Diverse Individuals’ Daily Experiences of Rumination

Abstract

Transgender and gender diverse (TGD) people face a myriad of daily stressors because of the hegemonic gender norms embedded within U.S. society. Due to these minority stressors, TGD people report elevated anxiety, depression, stress, and suicidality, among other health issues. One mechanism through which stigma may lead to these negative mental health outcomes is through increased rumination. In this intensive daily diary study with 181 TGD individuals (ages 16–40), we gathered qualitative data on their ruminative thoughts over the course of 56 days. There were a total of 2,431 responses across participants, with individuals providing a range of 1 to 53 responses (M = 15 responses). Using an experiential framework and an inductive approach to thematic analysis, we generated the following themes: 1) Interpersonal relationships as a site of struggle; 2) Fear and worry in response to contextual factors; 3) The weight of basic needs and safety; 4) Gender as experienced through self and others; 5) Intersections of health and rumination; and 6) The occasional reprieve. Using a deductive approach, we also placed these data within the context of Bronfenbrenner’s Person-Process-Context-Time model to provide a conceptual model for future research in this area. These ruminative experiences revealed significant adversities and challenges weighing on participants’ minds that spanned many areas of life. These findings also highlight the nuanced nature of rumination for TGD individuals and areas that may be overlooked in current assessments of this construct.

Despite growing recognition of the experiences of transgender and gender diverse (TGD) people (Crissman et al., 2017), general acceptance of TGD persons in mainstream society is still lacking (Norton & Herek, 2013). This unfortunate reality is evident in the widespread structural stigma that exists across the U.S., with TGD people lacking protections in areas such as housing discrimination and public accommodations, as well as efforts to ban TGD people from the military and the rolling back of healthcare access (White Hughto et al., 2015). This unwelcoming environment creates barriers to TGD people accessing basic needs and contributes to the many health disparities faced by this community (White Hughto et al., 2015).

Hegemonic gender norms are foundational to the rejection TGD people experience. Understandings of gender collapse it into a single binary with sex and sexuality (Butler, 1989). In short, in hegemonic terms, gender is a single binary that ties sex/gender/sexuality together, whereby one’s sex assigned at birth is either assumed to be male or female, which is then assumed to determine one’s gender and sexuality. This fictive vector of hegemonic ordering is perpetuated through performative routines deemed acceptable by society. Performative routines encompass every aspect of daily life and permeate society (Butler, 1989). Furthermore, society has created physical spaces to reinforce these routines, including binary public restroom facilities. TGD people live in a world where their very existence directly refutes a hegemonic vector of power that influences every level of society. This reality perpetuates the stigmatization TGD people face, which, in turn, contributes to a host of mental health disparities.

Marginalization and Health Disparities

Theoretical and conceptual models have demonstrated that minority stressors play a significant role in health disparities for TGD populations (Brooks, 1981; Meyer 2003; Testa et al., 2015). These minority stressors include overt forms of stigma, or distal stressors, as well as those stressors that arise in response to stigma, also called proximal stressors. At the proximal level, this can include internalized stigma, expectations of rejection, and – for some people – concealment of one’s gender identity or transition history (Testa et al., 2015). Similarly, socioecological models demonstrate that stigma across societal levels, such as the individual, interpersonal, and structural levels, partially drive health disparities for TGD people (Johns et al., 2018; Mocarski et al., 2019; White Hughto et al., 2015).

Research aligns with these theoretical frameworks, showing that TGD people experience stigma from various sources with implications for their health and well-being. For instance, TGD people are disproportionately exposed to violence across the lifespan (Stotzer, 2009), unemployment, homelessness (James et al., 2016), and openly hostile work environments (King & Cortina, 2010). Estimates indicate that 1 in 4 TGD people will experience assault at school in grades K–12, 1 in 4 will experience homelessness for at least a portion of their lives, and many live in extreme poverty (James et. al., 2016). Furthermore, even when examining experiences over the past year only, 3 out of 4 TGD people report exposure to discrimination (Puckett et al., 2020). These data indicate that stigma is pervasive and impacts many domains of TGD people’s lives.

As a product of these adverse life experiences and marginalization, TGD individuals also experience elevated rates of anxiety, depression, post-traumatic stress disorder, alcohol and drug abuse, and suicidal ideation (Bockting et al, 2013; Haas et al., 2010; Lombardi, 2001). In addition, a sobering 40% of TGD individuals have attempted suicide compared to 1–2% of the general population (James et al., 2016). These statistics brush the surface of the impacts on TGD health that arise from the systematic bias, discrimination, marginalization, and abuse they experience daily.

A Mechanism Underlying the Psychological Toll of Stigmatization: Rumination

It is not enough to simply understand the structural and interpersonal factors that uphold the marginalization of TGD people, we must also understand their mechanisms of actions. The importance of identifying mechanisms can be seen even in early writings about minority stress by Virginia Brooks (1981): “Minority stress, then, can be viewed as a state intervening between the sequential antecedent stressors of culturally sanctioned, categorically ascribed inferior status, resultant prejudice and discrimination, the impact of these forces on the cognitive structure of the individual, and consequent readjustment or adaptational failure” (p. 84). In more recent writing, Hatzenbuehler (2009) described various identity-specific and general psychosocial mechanisms that help explain how structural and enacted forms of stigma influence mental health via a psychological mediation framework. Specific to individuals with marginalized identities, overt or enacted stigma may result in what Meyer (2003) conceptualized as proximal stressors (e.g., internalized stigma). General psychosocial mechanisms may include cognitive mechanisms (e.g., hopelessness, negative self-schema), social/interpersonal mechanisms (e.g., social isolation, social norms), and coping/emotion regulation mechanisms (e.g., coping motives, rumination; Hatzenbuehler, 2009). In total, these factors may help explain how stigma comes to influence mental health.

Our study focused on rumination specifically as one response that may be activated by stigma or stressors and lead to negative mental health consequences. Given rumination is a robust predictor of various health outcomes (Nolen-Hoeksema, 2000; Timmins et al., 2017), this response to stressors warrants further examination. Rumination is a coping/emotion regulation mechanism in the psychological mediation framework (Hatzenbuehler, 2009). Rumination is defined as a repetitive focus on one’s feelings or events and circumstances that have influenced their emotional experiences (Nolen-Hoeksema, 1991). Rumination in response to identity-based stressors may include: a sense of hypervigilance, a fear of one’s identity becoming known by others, attempts to suppress thoughts related to stigma, heightened self-focus within interpersonal exchanges, and self-monitoring (Hatzenbuehler, 2009).

Although research demonstrates that rumination plays a role in depression and anxiety in both the general population (Nolen-Hoeksema, 2000) and samples of TGD people (Timmins et al., 2017), little research has explored how TGD people experience rumination or the content of this psychological process. Bauerband and Galupo (2014) developed the first scale to measure rumination in TGD people, including three subscales: reflection about gender identity (a more positive reflection on one’s gender experience), rumination about gender identity, and preoccupation with others’ perceptions. Their study revealed unique forms of rumination that TGD people may experience that center their gender experience and the interpersonal/social dynamics specific to their lives. In line with the psychological mediation framework, their findings show that rumination may be higher when individuals report more exposure to stigma. They also demonstrated that general measures of rumination only accounted for 25–26% of the variance in scores on the Gender Identity Reflection and Rumination Scale. These findings suggest there are nuances specific to being a gender minority that may uniquely shape the very experience of rumination and that general measures of this construct may not suffice.

Other research also supports that ruminative responses may be triggered by external stressors that are identity specific. For instance, Gonzalez and colleagues (2018) found that cisgender and TGD people who were sexual minorities (identified as lesbian, gay, bisexual, queer, or other non-heterosexual identities) reported increased vicarious trauma, vigilance, and rumination after the 2016 election. In addition, others have found that experiences of invalidation of non-binary individuals’ identities are associated with a range of cognitive responses, including rumination about mistreatment, their gender experience, and subsequent feelings of internalized shame (Johnson et al., 2020). As a consequence of rejection and social marginalization, TGD people may understandably learn to expect rejection in many, if not all, social contexts and may be on alert for these experiences (Rood et al., 2016). After such events, cognitive strategies for managing the associated distress can include ruminative thinking about the event and about feelings of anger and frustration regarding the rejection (Rood et al., 2016).

In alignment with the psychological mediation framework, research supports that rumination may help to explain the effects of stigma – even when examining general forms of rumination that are not TGD specific. Rumination has been found to mediate the associations between prejudiced events, self-stigma, identity concealment, and expectations of rejection with psychological distress (Timmins et al., 2017). Rumination was also found to mediate the association between three minority stressors (victimization, microaggressions, and internalized stigma) and depression in a longitudinal sample of young men who have sex with men and young transgender women (Sarno et al., 2020). Collectively, these studies show that rumination is a common experience for TGD people and is vital to explaining mental health disparities in this population. Furthermore, rumination may also be a common treatment target when working therapeutically with marginalized communities (e.g., Heck, 2017) and deepening understandings of this construct may benefit clinical practice with TGD people.

Current Study

We detail in-depth qualitative data about the content of TGD people’s ruminative thoughts throughout a daily diary study involving 56 days of data collection. This intensive data collection allowed us to gain insights into the types of rumination experienced by TGD people and the role this may play in health outcomes. Given that rumination is an important process through which stigma and other social determinants of health come to impact TGD people (Hatzenbuehler & Pachankis, 2016; Hatzenbuehler et al., 2013), learning more about these experiences may shed light on avenues for promoting resilience in the face of these adversities.

Method

Participants

The full sample included 181 TGD individuals (including trans men, trans women, and genderqueer or non-binary participants) ages 16 to 40 years (M = 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%, was 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 study entailed two components: 1) a daily diary study focused on understanding the associations between marginalization stress, mental health, substance use, and sexual behaviors, and 2) a one-time survey about marginalization stress, mental health, and related variables. For inclusion in the daily diary study, individuals had to be between ages 16–40 years old, identify as a trans man, trans woman, genderqueer, or non-binary person, lived in the U.S., had sex in the past 30 days, and either binge drank or used substances in the past 30 days. Any respondents who did not meet these criteria but who were at least 16 years old, TGD identified, and living in the U.S. were invited to participate in the one-time survey. The data presented in this manuscript are specifically from the daily diary study only, with both described here to provide context for the overarching project.

Individuals who qualified and were enrolled in the daily diary study first completed a baseline questionnaire and then received daily surveys for 56 days (i.e., 8 weeks). The daily surveys measured experiences such as mood, marginalization stress, substance use, rumination, and other related constructs. On the seventh day of each week, participants received a slightly longer version of the survey that included an extended assessment of mental health over the prior week. Finally, participants received a brief survey at the end of the 8 weeks that followed up on some of the constructs measured at baseline. Participants were paid $50–60 (range reflects additional funding that was acquired after the study began) for completing at least 85% of the surveys and $20 if they completed less than this but at least half of the days.

Participants were recruited online through multiple social media platforms, such as Facebook, Twitter, Tumblr, and others. In addition, we shared the electronic study flyer with various community organizations that worked with TGD individuals and shared study information in person at community events. There was a waiver for parental permission for participants who were ages 16–17 and the study was approved by the Institutional Review Board at Northwestern University and the University of South Dakota. In addition, given that this was an online study, we took several steps to ensure the quality of the data collection (these are described elsewhere; see Puckett et al., 2021). We also incorporated a community advisory board of local TGD individuals who helped to provide feedback about the study aims, questions, and preliminary data interpretations.

After cleaning the data, there were 181 participants enrolled in the daily diary study. Of these, there were 177 participants (97.8%) who completed at least one entry in the daily survey portion of the study. A total of 145 participants (80.1%) completed the final follow-up survey at the end of the 8 weeks. Of the 177 participants retained in 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. For these 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 for participants ranged from 0 to 47 days.

Measures

Demographics.

Participants provided basic demographic information, including age, gender, sex assigned at birth, sexual orientation, race/ethnicity, income, and education. A breakdown of participant demographics is available in Table 1, along with the response options for these items.

Rumination.

Participants were first asked “Yesterday, did you have a hard time getting things off your mind? This includes things that are completely unrelated to your gender identity.” If they indicated “yes” they were asked to elaborate on the content of their rumination (“Briefly, tell us what you weren’t able to stop thinking about.”). Participants were also asked to indicate how strongly what they wrote about was related to their being TGD or not: “How much do you feel like this was related to your gender identity?” (1 = Very Strongly Related; 5 = Not Related at All). This last question was used to aid in interpretation of the written responses. For instance, if someone wrote “financial strain” without any elaboration, this rating scale helped to understand whether the participant was referencing general stressors or TGD specific ones.

Analyses

SPSS was used for descriptive statistics, frequencies for demographic variables, and describing endorsement of the rumination variable. All qualitative analyses were conducted in NVivo. We conducted a thematic analysis for the qualitative responses (Braun & Clark, 2006) to explore how rumination manifested and was experienced by TGD individuals. Originally, we used an inductive approach to coding that was data-driven and included both semantic and latent meanings. This initial coding was based on an experiential framework in which we sought to describe participants’ experiences of rumination. We followed a modified process for the thematic analysis using the phases outlined by Braun and Clark (2006) to facilitate coding by two researchers. The first author reviewed the data and established an initial codebook with labels for codes and definitions. The first and second author then coded 10% of the data using this codebook and revised it for clarity and additional codes. Following this, the second author applied the codebook to the data and this coding was reviewed by the first author. In addition to these coding reviews, the first and second authors met to discuss the coding to ensure alignment in approach and application across coders. Afterward, we clustered the codes into themes organized around a central concept in the data. The first author also reviewed each theme to ensure that the data within each theme was consistent with the meaning. The first author also reviewed the themes in light of the full dataset to ensure that other themes were not a better fit for describing participants’ experiences.

During the analysis, we found that participants’ descriptions of rumination consistently drew connections between psychological experiences and the various relational and social spheres they were embedded within. This led to a second analysis of the data using a deductive approach wherein we utilized the Person-Process-Context-Time (PPCT) model to guide data coding. The PPCT model is an iteration of Bronfenbrenner’s socioecological model that details how social context and systems influence the individual (Bronfenbrenner, 1973; Bronfenbrenner & Morris, 1998). In comparison to the original socioecological model, the PPCT model more thoroughly integrates the individual’s experiences within a particular context in relation to their own developmental stage, the historical moment, and in light of their individual predispositions or characteristics. We developed codes that aligned to the major components of the PPCT model. We coded the data for information that would align with each layer of the systems described in the model, such as interpersonal experiences or those within organizations. We also coded the data for experiences related to time and personal characteristics that influenced rumination. Finally, we coded for proximal processes, which are the experiences of interactions between the person and others in their environment or objects and symbols in their environment.

We present findings from the inductive approach to coding to more fully detail the ways in which participants experienced rumination. This is followed by the findings from the deductive approach to coding, which offered an opportunity to extend the PPCT model to TGD individuals’ experiences of rumination. These two approaches to the coding offered novel information – inductive coding offered richness in understanding the ways in which rumination manifests and the deductive coding offered theoretical advancements in describing rumination as a socially embedded phenomenon influenced by person, time, and place.

Results

Across all participants and all days, there were a total of 2,425 written responses describing rumination, which were provided by 165 participants (98.8% of participants – all but 2 participants – retained in the daily surveys). Of the participants who responded, these ranged from 1 to 53 responses over the 56 days (M = 15 responses). To provide an estimation of how many days participants were ruminating, we calculated the percentage of days each person reported ruminating out of the total days they provided any data (see Table 2). On average, participants reported rumination on 34.8% of the days they responded to the survey.

Table 2.

Endorsement of Rumination in Daily Survey

% of Days Reporting Rumination	Participants who Endorsed Rumination n (%)
0–19.9%	57 (34.13%)
20–39.9%	49 (29.34%)
40–59.9%	28 (16.77%)
60–79.9%	15 (8.98%)
80–100%	18 (10.78%)

Note. Percentages of days calculated based on the number of days participants responded to the survey.

Findings from Inductive Analyses

Table 3 contains a list of themes and the percentages of participants included in each theme. There were six themes that were generated based on the data: 1) Interpersonal relationships as a site of struggle; 2) Fear and worry in response to contextual factors; 3) The weight of basic needs and safety; 4) Gender as experienced through self and others; 5) Intersections of health and rumination; and 6) The occasional reprieve. These themes highlighted the ways in which participants experienced rumination, triggers for rumination, and how this impacted their functioning. Each theme and the codes within each theme are described, with quotes to illustrate the findings.

Table 3.

Themes from Inductive Qualitative Analyses

Interpersonal Relationships as a Site of Struggle (n = 131; 78.9%) - Experiences with Friends and Family - Sexuality - Misgendering - Fears about Disclosure - Being Outed by Others - Connections and Disconnections from other TGD People and Communities

Fear and Worry in Response to Contextual Factors (n = 89; 53.6%) - Enacted Stigma - Sociopolitical Stressors - Vicarious Stress - Limited Future Orientation

The Weight of Basic Needs and Safety (n = 128; 77.1%) - Employment Concerns - Financial Concerns - Housing Concerns - Issues at School - Safety Concerns

Gender as Experienced Through Self and Others (n = 103; 62.05%) - Dysphoria - General Dislike of Body/Appearance - Concern about Others’ Perceptions of Gender

Intersections of Health and Rumination (n = 113; 68.07%) - Mental Health Issues - Loss (Past and Anticipated) - Healthcare and Medical Concerns

The Occasional Reprieve (n = 6; 3.62%)

Note. Percentages correspond to the 166 individuals who provided rumination responses.

Interpersonal Relationships as a Site of Struggle

The most common topic of rumination across all themes was about interpersonal challenges faced by participants. Participants reported rumination related to their experiences as TGD people in a variety of relationships, including: friendships [e.g., “Worry about encountering a former friend, and distress at a friend’s insistence on referring to me and herself as ‘girls’ (I’m not out to her).”], intimate relationships (e.g., “Scared i will never find a stable relationship with someone who respects my gender and sexuality.”), and within their families:

My mom keeps reminding me I am her only son, and is disappointed in me. I also could not get over feeling depressed, because I cannot just be myself, and show the [world] how beautiful I can be as my true self.

Because TGD people’s experiences are not solely gender related, participants also commented on interpersonal experiences in these domains that were not specific to being TGD. For example, one participant wondered “Why my friend didn’t stop to see me when he drove through the state.” Other responses reflected an emphasis on sexuality, such as “I thought those two new people were cute. AM I STILL ACE?”

Within these interpersonal relationships, ruptures and fear were common. One example of these types of challenge was misgendering. Misgendering occurs when a TGD individual is referred to in ways that differ from their gender identity, such as via pronouns or given names. Misgendering can also happen via interpersonal actions that treat people in gendered ways that are invalidating, such as mannerisms. Misgendering happened across many facets of TGD people’s lives – work, school, family, friends, and strangers. Participants were misgendered by people who knew them and those who did not have existing relationships with them. For those with existing relationships, participants often reflected on these individuals intentionally misgendering them, such as:

A card my parents sent for my birthday finally came in the mail… the card was addressed to their daughter. They have one daughter, and her birthday isn’t until December, and one son, me, whose birthday is in June. I fear that they will never accept this.

Furthermore, misgendering can greatly hinder a TGD person’s ability to participate safely in their daily life, such as in this participant’s response: “I was misgendered in class for the first time in a very long while, I reacted defensively and people subsequently mocked my defensiveness. This was incredibly distressing; [I’m] nervous about even going to class this morning.”

Participants also reflected on degrees of openness and the closeness they felt to others in their lives. Some rumination responses reflected worries about disclosure of participants’ TGD identities (e.g., “trying to figure out ways to come out to more people and the fear of doing that”), whereas others focused on explicitly being outed by others. Other rumination responses were about connections (e.g., “It was Pride! I marched in the trans parade, and was overcome with positive emotions.”) or disconnections (e.g., “I’m never going to meet someone else who is trans. I’m gonna go through this alone.”) with other TGD people and communities.

Across these responses, instances such as ruptures in interpersonal relationships, misgendering, or outright rejection left many participants feeling that others did not respect their TGD identities. These interpersonal relationships had implications for feeling invalidated in participants’ gender experiences and for their own sense of self. The internalization of these interpersonal challenges was reflected when participants questioned what their experiences or others’ reactions ultimately meant about them.

Fear and Worry in Response to Contextual Factors

Participants reported a range of oppressive experiences that resulted in heightened fear and worry. Participants ruminated about times where they were directly targeted and stigmatized and about oppression experienced within the broader sociopolitical context. Due to these contextual factors, participants were left feeling on edge, fearful, and worried about their futures. This theme reflected the types of contextual experiences and factors that led to this fear and worry and the reactions that participants had to these events.

Enacted stigma manifested in a variety of ways. Sometimes these were events that happened over the previous day or during the duration of the study (e.g., “Some asshole on grindr freaked out on me and said a bunch of awful shit.” and “Started my period and was assaulted for being trans.”). Other times, these were memories about past experiences that were troubling participants. For instance, one participant described working for the fire department and being left inside a burning building by co-workers:

… Still fearful of coming out at work. The fire department is a tough place to survive if you are different… At the first department I worked for and I was put into a training fire… They left me in there and would not let me out. They wanted to see if I was truly man enough to do the job. I received 2^nd and 3^rd degree burns and melted my fire helmet, and air-pack mask… that still haunts me.

In the sociopolitical realm, participants wrote about a variety of events that were on their minds, including: 2016 election (e.g., “The election. Wondering how trans rights are going to be rolled back in this country. I’m from [conservative southern state], so wondering if it will ever be safe to move home.”) and the process leading up to determining who would be running in the election (e.g., “ [state] primaries”), general comments about the administration at the time (e.g., “Trump being a rapist piece of shit” and “Trump pence. It will take four years to get that off my mind.”), the resulting cissexism and other bias that was emboldened throughout the country in the aftermath of the 2016 election (e.g., “How the people closes to me, my family, have been incredibly racist and homophobic since the election.”), policy changes that were implemented (e.g., “The section of title nine that was taken away by the trump administration protecting trans students.” and “Trump’s trans military ban…”), mistreatment when trying to resist this oppression (e.g., “The police violence we encountered during the protest, flash bangs, tear gas, pepper spray.”), and the broad fear for what this meant for participants’ own lives (e.g., “The election results and what this means for my future.”). Throughout these narratives, it was clear that participants felt the personal impact of the sociopolitical context in which they were living.

Related to the toll of broader social issues on individual TGD people, a unique stressor that arose in the rumination responses was vicarious stress. This referred to the emotional toll of exposure to stress narratives from other TGD people or social representations of TGD people or LGBTQ+ people more broadly. For instance, during the study, the Orlando shooting occurred at the Pulse nightclub and many participants wrote about feeling personally impacted by this. Other stories also activated these types of concerns, such as the public coming out of Caitlyn Jenner and the media attention to her story: “Feeling unsafe because of Caitlyn Jenner being in the news and people saying ignorant things around me.” Although important and powerful, this type of visibility also came at a cost for TGD people because of associated backlash or public displays of cissexism. Another salient event that occurred during the study that activated this stressor was the 2016 election: “trump winning the election and how scared I am for my trans friends in less accepting areas.” Other responses in this category expressed concerns for TGD people being murdered (e.g., “My trans kindred are dying.”), worry about how other TGD people were being mistreated and trying to help them (e.g., “Transgender high school student client is being expelled for responding to bullying by administrator with raised voice and inappropriate language. I am preparing for the manifestation determination hearing instead of sleeping.”), and other general exposure to cissexism (e.g., “I couldn’t get transphobic language from people on facebook off my mind.”).

Some participants expressed generally having heightened worry about their futures – or, a limited future orientation. This concept included references to a shorter future or a future with a lowered quality given the stigma that TGD people face. These responses often emphasized a sense of hopelessness about being able to live in an affirmed gender (e.g., “feeling like I’ll never be seen for the person I really am and that none of this is worth it”). Fears of rejection sometimes brought on this hopelessness (e.g., “People kept asking me about post graduation plans and I couldn’t stop thinking that I don’t know how I will fit into nursing as a trans person particularly if I’m transitioning as I’m interviewing”). Other times this hopelessness was brought on by thoughts about being targeted with violence or being killed (e.g., “I was worried about the future. What if Trump gets elected and this country starts heading down a path of purging everyone not deemed normal. I’ll definitely be taken and killed for being trans.”).

The Weight of Basic Needs and Safety

The toll of living in a stigmatizing context was notable, with participants facing many challenges to getting their basic needs met and maintaining their safety. Participants shared challenges in employment that spanned from generic (e.g., “my boss got angry at me”) to those specific to their experiences as TGD people. Participants ruminated about fear related to how other people may perceive them in the workplace if they took steps to affirm their gender (e.g., “how a binder would affect my appearance at work”). They also expressed a deep fear for their safety if their gender was known within workplaces. This participant’s response shows the danger that may arise for TGD people:

I am having a hard time with work because some suspect my status there, and that can cause me to get hurt or worst. As a firefighter and paramedic I have always helped people regardless of their differences, but the rest there do not share the same mentality and discriminate against those while on emergency scenes.

Financial stability is core to being able to provide for one’s self, which is compromised with employment challenges. Participants frequently endorsed financial hardships that consumed their thoughts, such as simply not having enough money to meet one’s needs (e.g., “I have only enough money for rent and food”) or specific bills (e.g., “student loans”). Rumination about finances also related to access to living in participants’ affirmed gender identities, such as affording the costs of affirming one’s gender, buying a binder, purchasing clothing that aligns with one’s gender, covering the costs of medical care associated with gender affirmation, and other gender affirmation related costs, such as therapy. These challenges in financial realms were also connected to structural issues like access to identification documents that matched participants’ genders and identities, such as the following participant’s experiences:

I’ve been leaving the house less and less lately. I wish I felt comfortable enough to have a job. I wish I had the money to do a name change right now. I hate having my ID checked and I hate using my debit card and I hate having to look anything up by my name. I just want to be able to live my life and not have anxiety about such a small thing.

Financial strain also had implications for housing (e.g., “I was worried that we would be evicted.”).

Some participants also wrote about their experiences at school, including worries about completing assignments, doing well in classes, applying to graduate school, and other general concerns. However, they also included responses that were specific to being TGD, such as this: “I couldn’t get off my mind that my school still hasn’t fixed my log in from the deadname and worry about that being on the screen on my powerpoints in front of other students.” This example resonated across many responses, as systems that denied TGD people ways to affirm themselves left them not only being misgendered but concerned about their safety.

These hardships and systems that created inequitable access to resources for TGD people compromised their feelings of safety. A lack of financial and housing stability left participants worried for their well-being, whereas concerns related to school had the potential to foreclose on gaining such stability. In addition, many participants commented about spaces or situations they felt unsafe in, such as restrooms (e.g., “The bathroom security call situation.”) or when traveling (e.g., “I recently left my job after 10 years. I couldn’t stop thinking about what to do next. I’m considering international traveling and working, but am concerned about traveling while trans and the various issues I might face.”).

Gender as Experienced Through Self and Others

Ruminative thoughts also specifically revolved around participants’ experiences of their gender, their bodies, and the intersection of these experiences with other people and the contexts of their daily lives. Unique to TGD people, a focus on the body included rumination about dysphoria, as well as a hyperawareness of how others were reading or perceiving their body and gender. These types of worries may come up due to risks of being targeted when known as being TGD. As such, these were likely adaptive responses to the violence that many TGD people face daily, yet these thoughts may also weigh heavily on TGD people.

Participants related to their bodies in ways that preoccupied their thoughts. In regards to dysphoria specific responses, these included references to wanting gender affirming medical care (e.g., “I hate my chest and want surgery”), recovering from gender affirming medical procedures (e.g., “still healing from top surgery, wishing my results were better”), the psychological impact of dysphoria (e.g., “feeling hopeless and having lots of internal dysphoria around my gender identity”), and situations or contexts that caused peaks in dysphoria (e.g., “my body dysphoria when my partner wants sex”). The other responses about participants’ bodies were broader in focus and included statements about general attractiveness (e.g., “And I’m 30 and that’s like a major cutoff age for being considered attractive”), health (e.g., “not in shape”), and weight concerns (e.g., “I feel like I’ve gained so much weight and I need to cut back on eating).

Participants also expressed concern for how others perceived their genders, often explicitly related to their bodies. This included times where participants were concerned about how others’ perceptions would relate to their safety (e.g., “I’m traveling abroad this summer and am worried about it I’ll ‘pass’ and how that will impact my safety”), frequent thoughts questioning how others perceived participants (e.g., “Worrying about being clocked while out at the movies and to dinner”), reactions to being perceived in ways incongruent with participants’ genders (e.g., “My mustache is in full bloom after laser treatment and I look completely male again. Everyone staring at me.”), and anxious thoughts about interacting with others (e.g., “I’ve been thinking about binding and how I’d feel in social situations if I do.”). Some responses focused on fears of disclosure related to a TGD identity (e.g., “I could not stop wondering how others would treat me if they truly knew how I felt.”), reactions to disclosure to others (e.g., “Welp, I just outed myself to two co-workers. Are they gonna think differently of me? Are they gonna tell others? Do I give a shit?”), and concerns about how others generally think about TGD people (e.g., “Worrying about how people think being nonbinary is fake”).

Intersections of Health and Rumination

Participants’ general health and well-being also influenced experiences of rumination. Some participants wrote about mental health concerns that were impacting them, such as depressive symptoms, suicidal ideation, or trauma responses (e.g., “couldn’t stop thinking about past trauma/abuse.”). Coping with dysphoria also intersected with mental health and rumination, such as this participant’s experience: “I cut myself yesterday because of my discomfort and being off hormones for 7 months now. Just found out it will be another 3 months till I can get in to see a doctor and its bullshit.” Participants’ mental health concerns were contextually embedded with particular events triggering emotional reactions that promoted rumination (e.g., “Orlando really got to me, I felt like I was on the edge of crying all day.”).

Rumination also appeared to be triggered by both past and anticipated losses. Some participants wrote about family members who were ill (e.g., “my dad is dying”) and others wrote about family members who were deceased (e.g., “the anniversary of my father’s death is coming up.”). Some participants also reflected on the deaths of TGD people they knew, which held an added significance related to expectations for their own future, such as this participant: “thinking about a friend that had been murdered for being trans and how that could be me.”

Several participants also shared rumination about healthcare and medical concerns. Some of these responses were about interactions with healthcare providers. For instance, participants wrote about troubles finding providers (e.g., “finding a therapist”), thinking about appointments (e.g., “having to make a gyn appointment”), and mistreatment (e.g., “Medical discrimination. An endocrinologist I was seeing for the first time spent 15 minutes trying to scare me out of transitioning.”). Others encountered issues with their insurance in obtaining gender-affirming care, which resulted in hardships (e.g., “Just feeling sad that I’m going to be without T for a while.”). Participants also wrote about steps in their gender affirmation process, such as distress associated with anticipating barriers to obtaining gender affirming procedures (e.g., “I’m very nervous about my pre-op appointment and how I will feel if my insurance denies me coverage.”). Finally, participants also wrote about general medical concerns (e.g., “chronic back pain”) and feeling ill (e.g., “my fever”) that increased their rumination.

The Occasional Reprieve

A few participants also mentioned positive life experiences that they were thinking about, which stood in stark contrast to the challenges and hardships that consumed many days. This included name changes (e.g., “I went through the process of legally changing my name yesterday”), major life events (e.g., “I got into [Ivy League School]!”), and interpersonal acts of affirmation [e.g., “I have great friends, one of which called me by my chosen pronouns (they/them/their) the day before yesterday, it was the first time anyone had done it for me and it was the best feeling.”].

Findings from Deductive Analyses: The Person-Process-Context-Time Model

To add to the conceptual understandings of gender minority stress, we place these data into the PPCT model (see Figure 1). In regards to proximal processes, these refer to experiences of iterative interactions between the person and others in their environment or objects and symbols in their environment. Figure 1 provides an overview of the proximal processes that were generated from the data. In relation to the systems participants were embedded within, at the interpersonal level relationships included friends, family, supervisors, peers, instructors or educators, students, advisors, coworkers, customers or clients, romantic and/or sexual partners, therapists, medical providers, security personnel, political leaders, strangers, TGD community, and the broader LGBTQ+ community. The contexts or systems mentioned included: region, state, city, community events and centers, work, school, hospitals, medical offices, stores, restaurants, public settings, social media and apps, restrooms, and home. Time also influenced rumination by shaping reflections on the past and anticipation for the future in relation to the current historical moment participants were living in.

Figure 1.

Ruminative Processes within the Person-Process-Context-Time Model

A review of the data also highlighted various person-level characteristics that influenced the participants’ life experiences and rumination. These included the participant’s gender expression/appearance (e.g., “My face looks like a guys, I have stubble, the skin where the stubble comes in has a weird texture. My brow ridge is too thick. I feel like everybody can see my stubble despite repeated reassurances by my girlfriend that I don’t look like a guy, or that my stubble is visible.”), voice (e.g., “Whether my phone interview next week will clock me as trans and cost me a very good future”), gender fluidity, level of outness (e.g., “anxiety about work and my desire to be open there about my gender, coupled with the fear that my coworkers would dislike me because of it”), gender dysphoria, medical gender affirmation (e.g., “usually makes it hard to cry, but I haven’t had my shot in 2 weeks so I’m having a lot more volatile emotions about this.”), and physiological experiences (e.g., “I had a really heavy day on my period. I was scared to leave the house because I was having to change every 2 hours or so and do not feel comfortable doing that in a men’s restroom.”).

Discussion

The findings from this study reveal that rumination is a common experience for TGD people and can weigh heavily on the daily life of this marginalized group. These themes reflect lives embedded within social systems and structures that place TGD people in oppressive, marginalizing, and dangerous situations. The overwhelming nature of this rumination was exhibited by the fact that all but two participants reported ruminating over the 8 weeks, with the average number of responses being 15 days. Notably, some participants reported ruminating on as many as 53 of the 56 days. As other research has shown, rumination is associated with depression and other mental health challenges (Sarno et al., 2020). Given the prevalence of rumination in this sample, this may play a central role in mental health disparities TGD people experience due to social marginalization (White Hughto et al., 2015).

The content of the rumination responses reveals that TGD people are encountering oppression from many areas of life. Even general stressors, like attending school, finances, or relationships, are nuanced for this group. Participants found themselves targeted within many facets of society, from their interpersonal relationships to family, work, school, and simply when moving through the world due to the physical spaces that reinforce the hegemonic organization of U.S. society (Mocarski et al., 2019). Often, these experiences left participants feeling worried about their futures and sometimes resulted in hopelessness and a negative view of themselves. These concerns were brought on in response to rejection from others, being misgendered, experiencing political oppression, or encountering discrimination and violence. Stigma was fundamental to activating and maintaining these ruminative thoughts, leaving participants feeling disempowered in their social circumstances. These findings align with Hatzenbuehler’s (2009) psychological mediation framework that explains that rumination may be brought on by social stigma and can be a mechanism through which mental health is impacted.

As other research has shown (Bauerband & Galupo, 2014), TGD people experience rumination that is unique and not entirely captured by existing measures that are more general assessments of this construct. The data in this study also suggest that there are unique manifestations of rumination for TGD people. Examples of such rumination include reflections about misgendering, connection/disconnection from other TGD people, safety as a TGD person, gender affirmation, social narratives about TGD people, body-related thoughts, concerns over others’ perceptions of one’s gender, and the political restriction of TGD people’s rights and protections. These forms of rumination may have an added impact on mental health, beyond that of general ruminative experiences, given their connection to a person’s gender experience. In addition, future research may help to understand whether rumination about particular topics differentially relates to mental health. To accomplish this, measure development is needed that assesses the range of possible ruminative thoughts that TGD people report.

The ruminative experiences mapped onto the spheres reflected in the socioecological model as applied to TGD people (Johns et al., 2018; Mocarski et al., 2019; White Hughto et al., 2015) and in the PPCT version of this model (Bronfenbrenner & Morris, 1998). At the structural level, participants referenced social norms and gender policing, policies that targeted their rights and protections, inequalities related to housing and employment, disproportionate rates of murders of TGD people, sociopolitical shifts in power, as well as others. At the interpersonal level, participants referenced direct encounters with violence, misgendering, assaults, rejection, interpersonal slights, etc. At the person level, participants referenced their own mental health, levels of outness, internalization of stigma, anticipation of rejection, worries, and other responses. These findings highlight the socially embedded nature of ruminative experiences for TGD people, similar to findings by Johnson et al. (2020) that detail cognitive and affective responses to invalidation. Likewise, rumination may be a response TGD people have when trying to make sense of, cope with, and respond to daily marginalization (e.g., Johnson et al., 2020; Puckett et al., 2020; Rood et al., 2016).

Time was a unique factor in the PPCT mode. Time can refer to individual experiences and continuity/discontinuity of these life events, experiences across one’s life course, and experiences within the particular historical moment a person is living in relation to other past or future generational experiences. Participants’ experiences were shaped by their own reflections on their past, their anticipation for the future, and the intersection of these experiences with their current gender experience – which can be referred to as transitioning identity stress (DuBois et al., 2017). Finally, these experiences were also shaped by the historical moment which guided participants’ expectations for their own lived experiences.

Integrating these findings into the PPCT model provides a framework for contextualizing marginalization stress in both place and time, furthering our understanding of the variability in how stressors are experienced across people. This extension of the PPCT model also aids in identifying the underlying processes through which marginalization stress may occur or unique forms of marginalization stress. Research has only recently adapted marginalization stress (Brooks, 1981; Meyer, 2003) to include the specific lived experiences of TGD people (Puckett et al., 2021; Rood et al., 2016; Rood et al., 2017; Testa & Hendricks, 2012; Testa et al., 2015). As such, this study further documents the harms of misgendering (McLemore, 2018), describes how transitioning identity stress (DuBois et al., 2017) may manifest, and corroborates other novel stressors recently added to the literature – gender binarism, body-gender policing, vicarious stress, and bodily vigilance (Puckett et al., 2021). The findings also reveal an additional stressor of having a limited future orientation and research is needed to understand the impact of this stressor on mental health.

Our findings also support the bidirectional relationship between general psychological processes (e.g., rumination) and group-specific processes (e.g., expectations of rejection) proposed by Hatzenbuehler (2009). From participants’ responses, there appear to be strong links between their experiences as TGD people living in cissexist contexts and the ways that rumination may manifest or be experienced. For instance, when hearing about murders of other TGD people, participants reported increased expectations of harm and subsequent ruminative thoughts about their own safety and these murders. As such, stressors that are group-specific, like expectations of rejection, may inherently shape how rumination is experienced.

This study had several strengths including the intensive data collection, large number of responses, and the focus on rumination. Furthermore, the daily data collection method substantially reduces recall bias in the content of rumination and improves ecological validity. Even so, there were important limitations that should be acknowledged. First, although our recruitment spanned many forms and we made explicit efforts to recruit TGD people of color, we had limited representation of racial and ethnic minorities. It is possible that our findings, including the types of ruminative responses or which types of rumination were the most salient in the data, would be different in a sample with more participants of color. This limitation may inhibit the generalizability of the findings to the broader TGD community and future research is needed that explores rumination in a more racially and ethnically diverse sample. In addition, although the intensive survey methodology provided an abundance of data about daily experiences, it does not allow for the same depth of information that may be gleaned from other types of studies like qualitative interviews that will enable follow-up prompts and clarification of responses. Another significant limitation of this study is that the participants were limited to those between the ages of 16 and 40 who reported having sex over the past 30 days and who either binge drank or used substances over the past 30 days. Although these inclusion criteria were essential to the overall aims of the study, they may have biased our sample. Finally, although a few participants reported positive life events, these were minimal, which is likely due to the nature of the prompt. Future research is needed that explores positive experiences and strengths using intensive data collection methods.

In conclusion, from this study we were able to document the pervasive ruminative experiences of TGD people resulting from social stigma and marginalization and integrate this into a conceptual model that can aid future research. The findings show that social stressors have a significant toll on the well-being of TGD people, including their basic sense of safety and their sense of self. Given the socially embedded nature of the stressors that participants referenced in their ruminative responses, there also must be shifts in these social structures and oppressive forces to alleviate the distress imposed on TGD people.

Public Policy Relevance Statement:

Transgender and gender diverse (TGD) people commonly report experiencing rumination. The content of this rumination can range from everyday stressors, like finances, to novel experiences related to gender affirmation, interpersonal rejection, political oppression, and fears for safety.