Abstract
Transgender (trans) people experience profound mental health disparities compared with the general population, attributable in part to the psychological effects of gender non-affirmation. Despite the barriers to legal gender affirmation for trans people, little is known about its association with mental health. We therefore sought to determine whether having gender-concordant identity documents (IDs) is associated with mental health among trans adults in the USA. We hypothesised that having an ID that reflects one's preferred name and gender marker would be associated with reduced psychological distress and suicide risk. In this cross-sectional observational study, we obtained data from the 2015 US Transgender Survey, the largest cross-sectional survey of trans adults in the USA, with 27 715 participants. Eligible participants were adults (≥18 years), residing in a US state, territory, or overseas US military base; and considered themselves transgender, trans, genderqueer, non-binary, or similar. We excluded participants not living day-to-day in a different gender to the sex they were assigned at birth, participants who identified as crossdressers, and those missing data. The primary exposure of interest was whether all or some (vs none) of a respondent's IDs reflected their preferred name and gender marker. We examined associations with psychological distress (measured with the Kessler 6 scale) and suicide ideation, planning, and attempts in the past year, which we analysed using linear and modified Poisson regression models to examine associations with respondents' IDs. Of 22 286 respondents included in our analytic sample, 10 288 (weighted percentage 45·1%) had their preferred name and gender marker on none, 9666 (44·2%) on some, and 2332 (10·7%) on all of their IDs. Compared with those with no gender-concordant ID, respondents for whom all IDs were concordant had lower prevalence of serious psychological distress (adjusted prevalence ratio 0·68, 95% CI 0·61-0·76), suicidal ideation (0·78, 0·72-0·85), and suicide planning (0·75, 0·64-0·87), adjusting for potential confounders. Having some versus no concordant ID was generally associated with smaller reductions in distress and suicidality. Gender-concordant ID was not associated with suicide attempts (eg, adjusted prevalence ratio for all vs no IDs was 0·92, 95% CI 0·68-1·24). Possession of gender-concordant IDs might improve mental health among trans persons. Gender recognition policies should be considered structural determinants of transgender health. None.
Highlights
In the USA, 0·6% of adults, or 1·4 million people, are estimated to identify as transgender.[1]
We hypothesised that having an identity documents (IDs) that reflects one’s preferred name and gender marker would be associated with reduced psychological distress and suicide risk, e197 www.thelancet.com/public-health Vol 5 April 2020
Because name change and legal gender recognition policies are most relevant to trans people living day-today in a gender that differs from the sex they were assigned at birth, we excluded from this analysis participants who were not living full-time or part-time in a gender different from their assigned sex at birth (n=4344) and participants who identified as crossdressers (n=512)
Summary
In the USA, 0·6% of adults, or 1·4 million people, are estimated to identify as transgender (ie, to have a gender identity that differs from the sex they were assigned at birth, which can fall outside the gender binary).[1] According to the 2015 US Transgender Survey,[2] only 11% of transg ender (trans) people have their preferred name and gender marker on all identity documents (IDs) and official records Among those whose IDs were not congruent with their gender presentation, a third experienced denied access to services, harassment, or violence, or all three.[2] Despite these inequities, there is scant evidence concerning the health effects of legal gender recognition for trans people. IDs can be conceptualised as a structural determinant of health linked to “socioeconomic-political context [as they are] structural mechanisms generating social stratification and the resulting socioeconomic position of individuals”.5
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