Chapter 6: Behavioral Health Considerations for Transgender and Gender Diverse People

INTRODUCTION

There is increasing recognition that transgender and gender diverse (TGD) people have specific health care needs, including gender-affirming, evidence-based behavioral health care offered by trained, culturally responsive clinicians. Although TGD youth and adults experience a range of stressors related to their gender minority status and are at increased risk for various associated psychiatric and behavioral health problems, they experience numerous barriers to receiving appropriate behavioral health care.^1,2 This inequity is one reason for the disproportionate rates of mental health disorders, suicidality, substance use disorders, and functional impairments often reported in this population.

Historically, the field of psychiatry has often adopted a pathologizing stance toward TGD communities.^3–5 The 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) marked a diagnostic shift from “gender identity disorder” toward the relatively more affirming construct of gender dysphoria. However, this diagnostic evolution fell short of completely disentangling gender diversity from classification as a psychiatric disorder, which many TGD community advocates argue carries inherent pathologization, stigmatization, and an often false assumption of distress.⁵

Recent studies suggest that approximately 50% of gender minority adults meet diagnostic criteria for a psychiatric diagnosis, with more than one-fourth experiencing an anxiety disorder, more than one-third meeting criteria for major depression, 14–40% reporting a history of a suicide attempt, and 20% reporting a lifetime history of substance use disorder.^6–9 A large population survey of college students found that transgender people were more than twice as likely as their cisgender peers to have depression and anxiety diagnoses, self-injurious behaviors, suicidal ideation, and suicide attempts.⁸ Thus, there remains a great need for evidence-based behavioral health interventions that are culturally sensitive to and tailored for TGD people.

The purpose of this chapter is to contextualize behavioral health inequities and needs among TGD people across diagnostic categories within a gender minority stress framework; propose culturally responsive tailoring of evidence-based behavioral health clinical practices; and offer strategies for building responsive, affirming, and effective behavioral health services for TGD communities, in order to optimize mental health outcomes.

GENDER IDENTITY CHANGE EFFORTS

Gender identity change efforts are psychological approaches that aim to change a person’s gender identity to align with societal expectations based on their sex assigned at birth.¹⁰ While these efforts are often referred to as “conversion therapy,” we intentionally avoid this term as it falsely implies that these efforts constitute a legitimate clinical practice rather than a form of harmful discrimination rooted in societal stigma and transphobia. Approximately 13.5% of TGD people in the United States report a lifetime exposure to these efforts, amounting to an estimated 188,000 TGD U.S. adults.¹⁰ One study with a large national sample of U.S. TGD adults found that recalled lifetime exposure to gender identity change efforts is associated with more than twofold increased odds of a lifetime suicide attempt.¹¹ In the same ...