- This study examined mental health symptoms and substance use in 29,988 patients across six gender groups: cisgender men and women, transgender men and women and nonbinary adults
- Depression was most common and symptoms were most severe among nonbinary patients and transgender women; nonbinary patients assigned female at birth were most likely to have an anxiety disorder and had the most severe anxiety
- The severity of alcohol use did not differ across the transgender and nonbinary groups; however, nonbinary patients assigned male at birth were significantly more likely than patients with other genders to meet criteria for a substance use disorder
- Among patients who met criteria for alcohol and/or substance use disorder, only 1.1% of transgender men, 4.1% of cisgender women and 4.6% of transgender women attended at least one substance use treatment appointment
Transgender and nonbinary individuals are known to have a significantly higher risk of mental health symptoms and substance use disorder than their cisgender counterparts. However, few studies have examined differences in the prevalence of specific mental health conditions across subgroups of gender minority individuals.
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Especially little is known about people who are nonbinary—an umbrella term to describe individuals who experience their genders as being other than male or female. For example, their genders may be bigender, agender, genderqueer or genderfluid.
Amelia M. Stanton, PhD, postdoctoral fellow, Abigail Batchelder, PhD, MPH, staff psychologist, and Conall O'Cleirigh, PhD, director of the Behavioral Medicine Program in the Department of Psychiatry at Massachusetts General Hospital; and Kenneth H. Mayer, MD of the Fenway Institute; and colleagues have determined that the risk and severity of depression, anxiety and substance use disorder are greater for nonbinary than transgender adults, and they confirmed both groups have worse mental health than cisgender adults. Their report appears in PLOS One.
The study was conducted at the Fenway Institute, a large community health center in Boston that specializes in sexual minority and gender minority health care. Participants were 29,988 adults, average age 34, who completed at least one questionnaire related to mental health or substance use between October 1, 2015, and October 1, 2018.
The questionnaires routinely offered at appointments were the Patient Health Questionnaire–9, the Generalized Anxiety Disorder 7-item questionnaire, the Alcohol Use Disorders Identification Test and the Drug Abuse Screening Test.
Patients were considered transgender if they provided different responses to the questions "What is your gender?" (options were male, female and nonbinary) and "What was your sex assigned at birth?" (options were male and female). Six genders were studied: cisgender men and women, transgender men and women, nonbinary patients assigned male at birth (AMAB) and nonbinary patients assigned female at birth (AFAB).
Depression and Anxiety
- Compared with people of other genders, significantly higher percentages of nonbinary participants (34% AMAB, 37% AFAB) and transgender women (35%) met the criteria for a depressive disorder
- In addition, depressive symptoms were most severe among nonbinary individuals and transgender women
- Nonbinary AFAB participants were the group most likely to meet the criteria for an anxiety disorder (46%) and had the highest severity of anxiety symptoms
- The two transgender groups and the nonbinary AMAB group had significantly greater prevalence and severity of anxiety than the cisgender groups
Substance Abuse and Dual Diagnosis
- Cisgender men, most of whom were gay, reported the highest alcohol use of the six gender groups, and 11% of that group met the criteria for an alcohol use disorder
- The severity of alcohol use did not differ significantly across the transgender and nonbinary groups
- Compared with other genders, a significantly greater proportion of nonbinary AMAB individuals reported use of substances other than alcohol (18%), and that group was also significantly more likely to meet the criteria for a substance use disorder (10%)
Engagement with Care
- Among patients who met criteria for depression and/or anxiety, no more than half of each group was referred to and/or used in-house mental health services during the three-year study period; the groups least likely to attend such appointments were nonbinary AMAB patients (41%) and cisgender women (38%)
- Among patients who met the criteria for an alcohol and/or substance use disorder, engagement with substance abuse care was lowest for transgender men; only 1.1% attended at least one treatment appointment
- Although higher, the percentages of transgender women (4.6%), cisgender women (4.1%) and nonbinary AMAB patients (6.6%) who attended at least one substance use treatment visit did not statistically differ from that of transgender men
Recommendations for Clinicians
These study findings show that mental health symptoms and substance use vary across subgroups of gender minority individuals. For optimal management, clinicians should keep in mind for each subgroup the risk of certain diagnoses and the risk of poor engagement with care.
The importance of learning to provide culturally competent care to transgender, nonbinary and sexual minority patients cannot be overstated. Errors can include invalidating, avoiding or overemphasizing gender or sexual orientation; gender generalizing (e.g., assuming a singular trans experience); and gender pathologizing (e.g., stigmatizing trans identity as the cause of all problems).
Recommendations for Health Systems and Researchers
Assigned sex at birth and current gender should be regularly and affirmingly assessed and recorded. Otherwise, the mental health effects of gender minority stress could be attributed to other factors or missed entirely. Routine collection of gender data will also help researchers determine which unique resilience factors can be targeted and leveraged in treatment.
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