Depression And Anxiety In Transgender People
Depression and Anxiety in Transgender People
Jace M. Hodson
Introduction
Spike in Interest In Transgender Research As interest in the psychology community has spiked in regards to transgender people, so has the amount of research done involving and pertaining to them. Many researchers have chosen to focus on the relationship between being transgender and having a mental disorder(s). Research seeks to find if there is a correlation between being transgender and having symptoms of one or more mental disorders, and what causes mental disorders in transgender people. Specifically, anxiety and depression (anxiety disorder and depressive disorder, respectively) are the two mood disorders most commonly associated with being transgender. …show more content…
These topics will be as extensively explored as possible within the length of this research paper.
What is a Transgender Person? Before any research can be done pertaining to transgender people and mood disorders, it is necessary to have a clear grasp on what exactly defines a transgender person and what sets them apart from other people. Transgender, or trans*, is an umbrella term that encompasses identities including cross-dressers; drag queens and kings; transvestites; bigender, genderqueer, and gender-variant people; and, what will be focused specifically on for the context of this paper, male-to-female and female-to-male transsexuals, who are described as “transgender women and men, respectively, who feminize or masculinize their bodies through hormone therapy or surgery” (Bockting, Miner, Romine, Hamilton & Coleman, 2013).
Prevalence of Anxiety in Transgender People It is also worth mention that anxiety and depression disorders are more prevalent among transgender people than cisgender (non-transgender) people. Transgender people have been recorded as being depressive at least three times as much as the cisgender population, and to have anxiety disorders almost twice as often (Budge, Adelson & Howard, 2013). In fact, the comorbidity of depression and other mental health disorders (very often anxiety) is cited to be common in transgender people (Rotondi, Bauer, Scanlon, Kaay, Travers & Travers, 2011).
Literature Review/Discussion
Percentages of Anxiety/Depression Among Transgender People Among all of the research studies available, percentages vary (and can vary vastly) as to rates of depression and anxiety among transgender people. These percentages vary mostly due to differentiations in each study’s measurement of depression and anxiety—for instance, some studies’ qualifications are any depression experienced in a lifetime, some are limited to recent depressive behaviors, and some refer to both (Rotondi et al., 2011). The Trans PULSE Project reported that approximately two thirds of female to male transsexuals (FTMs) exhibited depressive symptoms (Rotandi et al., 2011). In the Gómez-Gil, Zubiaurre-Elorza, Esteva,, Guillamon, Godáz, Cruz Almaraz, Halperin, & Salamero (2011) study, 39% of transgender people experience symptoms of depression and 94% of transgender people experience symptoms/possible symptoms of anxiety. Bockting et al., 2011, released a study saying that transgender people had a 44% rate of depression and a 33.2% rate of anxiety. Meanwhile, Budge et al.’s 2013 study reported 48-62% of transgender people suffer from depression and 26-38% of transgender people suffer from anxiety.
Significance of variations. The greatest standout for variations of percentages is the percentage given for possible symptoms and symptoms of anxiety in the Gómez-Gil et al. study, at ninety-four percent. As this percentage is drastically different from all the others, it must and should be taken into account that the definition for anxiety symptoms in this study also included possible anxiety symptoms, i.e. not necessarily confirmed diagnoses of anxiety. The other studies may vary due to the fact that some studies specify symptoms of anxiety/depression and some studies specify that the actual disorder must be present. So with varying definitions of anxiety and depression from study to study, there are bound to be slight differences with all the percentages reported in each study.
Transphobia, Its Repercussions and Its Role One of the major concepts that depression and anxiety in transgender people is correlated with is transphobia. Transphobia itself is a hatred or disrespect towards transgender people, and stemming from transphobia certain acts may be performed.
Transphobic acts.
Transphobic acts can include, but aren’t limited to, physical assault, sexual assault, verbal harassment, and the intentional misgendering of a person (calling an FTM “she” or an MTF “he”). These transphobic acts can cause or lead to larger amounts of “isolation, depression, anxiety, suicide, violent victimization, substance abuse, pregnancy, and school or job failure” in transgender people than cisgender peers (Health Risks, 2011). All transgender people report experiencing anywhere from a moderate to high amount transphobia in their lives (Rotondi et al., 2011). As one could imagine, these acts can be very damaging to a transgender person, to the point of causing mental distress and even …show more content…
disorders.
Enacted vs. felt stigmas. Another aspect to transphobia is enacted vs. felt stigmas. Enacted stigmas are concrete “experiences of rejection and discrimination”, while felt stigmas are the expectations of being reacted negatively towards, and the internal image or stigma that a transgender person forms as a result of these negative reactions when they occur (Bockting et al, 2013). Enacted stigmas due to the transphobic actions of others can often trigger internal stigmas. Studies have shown that the higher the levels of both types of stigmas are, the more psychological distress a transgender person feels (Bockting et al, 2013). Thus, the stronger the transphobia is against a person, the more mental stress they feel, in terms of both anxiety and depression.
Social Support for Transgender People Transgender people often, due to internal and external stigmas, isolate themselves from their peers. This isolation, in addition to lowering outlets available for social support, “can exacerbate depression, anxiety, substance use, and suicidality”, all common characteristics of an unstable mental state (Rotandi et al., 2011). Thus social support is a very important component in the mental health of FTM and MTF transsexuals. Higher levels of social support. Research has shown that the presence of high “social support, self-acceptance, and integration of minority identity” can improve a transgender individual’s stress levels despite transphobia (Bockting et al., 2013). When peers provide high levels of support for an individual, that individual’s identity isn’t questioned or prejudiced against, he or she fits into the community of his or her peers, and can begin to view himself or herself more positively. Family support. Transgender individuals, unfortunately, do not get as much support as their cisgender siblings do from family (Budge et al., 2013). This is unfortunate when you consider that there is a “protective effect of supportive families” in that transgender people who are accepted by their families are more likely to be defended by their families, and thus not feel as alone as those without support (Health Risks, 2011). There in fact are “potential negative health effect[s] of punitive and rejecting behaviors” by family members, henceforth depression and anxiety can be worsened when families reject a transgender person’s identity and refuses to support him or her (Health Risks, 2011). Low levels of social support. Meier, Pardo, Labuski, and Babcock (2011) have found that the lower social support (and thus perceived quality of life) a transgender person has, the higher his or her depression or anxiety is likely to be. This lack of social support can in some cases cause an individual to become distressed socially, due to lack of friends, lack of interaction, or other social dissatisfactions. These social stressors can serve as one explanation for the larger amounts of depression and anxiety in transgender people than cisgender people, who fit in more easily with their peers and are far more likely to have a larger amount of friends and stronger support base in those people (Budge et al., 2013).
Coping Methods and Mechanisms Another factor that strongly influences depression among transgender individuals are the types of coping that they choose to employ. Coping in general is something that can ameliorate mental stress. Avoidant coping is a style of coping that happens when someone tries to predict and inhibit emotional responses to what is causing the stress, while facilitative coping requires a person to “find alternate means to seek happiness”, such as going to friends, altering his or her actions, and learning new ways to deal with situations (Budge et al., 2013).
Harmful ways to cope. Avoidant coping can have a correlation with “higher levels of depression, trauma symptoms, mental health problems, and internalizing/externalizing problems for transgender youth” (Budge et al., 2013). Avoidant coping is a particularly harmful strategy for transgender people. The more a person relies on avoidant coping, the more anxiety, depression, and overall mental stress is reported by that person (Budge et al., 2013). Another interesting fact to note is that the further along a person is in their transitioning process, the less likely they were to report using avoidant coping. Therefore, the further along in time a person is, the less likely they are to report having anxiety or depression.
The Transition Process for Transgender People The transition process for transgender people can include starting hormone treatments—testosterone for FTMs and estrogen for MTFs—as well as sexual reassignment surgeries, where the genitals are reconstructed to match a person’s gender rather than biological sex. Before treatment, transgender people reported anxiety 61% of the time, and depression 31% of the time. Whereas after treatment, transgender people reported having anxiety 33% of the time, and depression 8% of the time (Gómez-Gil et al., 2011). People in the planning stage of transitioning who experience and deal with the consequences of transphobia, who have yet to begin any sort of medical advancements toward their transition, face an even higher instance of reduced mental health. Starting hormone therapy. Findings show that there is a relationship between hormone therapy in transgender people and lowered levels of emotional disorders and adverse mental effects (Gómez-Gil, et al., 2011). In fact, the longer of a period of time an FTM transsexual is on testosterone therapy, the lower his depression, anxiety, and stress levels (Meier et al., 2013). This is likely due to the fact that the longer an FTM spends on testosterone, the greater the amount of social support that he indicates he receives (Meier et al., 2013). This social support, as discussed earlier, is an integral part of a transgender person’s self-acceptance and ability to view the world in a positive way. Not only does social support increase with the duration on hormone therapy, but so does quality of life, according to Rotondi et al.’s 2011 study. Sex reassignment surgery. Sex reassignment surgery consists of using the sexual organs that a person already has to construct a neophallus and testicles, or a neovagina and neoclitorus, for FTM and MTF transsexuals, respectively. Rotondi et al. (2011) say that post-operative transsexuals report lower depression than pre-operative transsexuals. The Gómez-Gil et al. study (2011) mentions that after treatment, transsexuals report that they have a higher quality of life than before surgery. This is likely due to the phenomena that people who “feel unattractive tend to have more social anxiety and to suffer mixed adaptive emotional disorders” (Gómez-Gil et al., 2011). This seems to indicate that hormone therapy in addition to surgery increases a person’s overall self-image, and increasing that self-image can lower mental distress and disorders. The further along a person is in his or her transitioning process, be it hormonal or surgical, the more likely he or she are to exhibit high hopes for his or her future (Budge et al., 2013). This is particularly important as high hopes for future indicate healing from and lessening of depression and anxiety.
Conclusion
Much research has linked being transgender to anxiety and depression disorders, and it is nearly impossible to refute the percentages that testify that transgender people face a higher likelihood of having one of these disorders than cisgender people. Causes possible for this phenomena may include the amount of family and social support received by a person, the amount of transphobia and stigma directed at a person, coping methods employed, and duration of hormones/progress along a person’s transition.
Facing and fixing the problem.
Though transgender people in present times face fewer emotional disturbances than transgender people did a mere ten years ago, the percentages are still very significant and very much higher than those of cisgender people (Meier et al., 2013). Prevention of depression and anxiety in transgender people should, according to Bockting et al. (2013), face the problems of “social structures, norms, and attitudes that produce minority stress for gender-variant people”, as well as providing peers with a better understanding and ability to support their transgender friends, and perhaps most importantly, an increased access to “mental health and social services that affirm transgender identity and promote resilience.” This seems like a hefty task, to attempt to change social structures, but it will come in time. However, for the current time being, it would be in the best interest of the mental health of transgender people for resources to be made more widely available to seek therapy that reinforces identity and mental health, as well as promoting the education of cisgender people in a way that they would be able to understand and support transgender
peers.
References
Bockting, W. O., Miner, M. H., Romine, R., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943-951. Retrieved from http://web.ebscohost.com/ehost/detail?sid=4f3a0b3a-8a05-4c26-8a2753aed5e3a4c5%40 sessionmgr11&vid=1&hid=11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=86141441
Budge, S. L., Adelson, J. L., & Howard, K. S. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81(3), 545-557. Retrieved from http://web.ebscohost.com/ehost/detail? sid=1cf4e51a-9232-4115-af040a9575eb5412 %40sessionmgr14&vid=6&hid=11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2013-04448-001
Gómez-Gil, E., Zubiaurre-Elorza, L., Esteva, I., Guillamon, A., Godáz, T., Cruz Almaraz, M., Halperin, I., & Salamero, M. (2011). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology, 35(5), 662-670. Retrieved from https://www.researchgate.net/publication/51660913_Hormone-treatedtranssexuals_ report_less_social_distress_anxiety_and_depression?ev=srch_pub
Health risks and needs of lesbian, gay, bisexual, transgender, and questioning adolescents position statement. (2011). Journal of Pediatric Health Care, 25(6), A9-A10. Retrieved from http://web.ebscohost.com/ehost/detail?vid=5&sid=1cf4e51a-9232-4115-af04-0a9575eb5412%40sessionmgr14&hid=11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2011-24613-005
Meier, S., Pardo, S. T., Labuski, C., & Babcock, J. (2013). Measures of clinical health among female-to-male transgender persons as a function of sexual orientation. Archives of Sexual behavior, 42(3), 463-474. Retrieved from http://web.ebscohost.com/ehost/detail? vid =5&sid=1cf4e51a-9232-4115-af040a9575eb5412%40sessionmgr14&hid=11&bdata= JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2013-01063-001
Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and Risk and Protective factors for depression in female-to-male transgender Ontarians: Trans PULSE project. Canadian Journal of Community Mental Health, 30(2). Retrieved from http://cjcmh.metapress.com/app/home/contribution.asp? referrer=parent&backto=searchcitationsresults,1,1;
Jace M. Hodson
Introduction
Spike in Interest In Transgender Research As interest in the psychology community has spiked in regards to transgender people, so has the amount of research done involving and pertaining to them. Many researchers have chosen to focus on the relationship between being transgender and having a mental disorder(s). Research seeks to find if there is a correlation between being transgender and having symptoms of one or more mental disorders, and what causes mental disorders in transgender people. Specifically, anxiety and depression (anxiety disorder and depressive disorder, respectively) are the two mood disorders most commonly associated with being transgender. …show more content…
These topics will be as extensively explored as possible within the length of this research paper.
What is a Transgender Person? Before any research can be done pertaining to transgender people and mood disorders, it is necessary to have a clear grasp on what exactly defines a transgender person and what sets them apart from other people. Transgender, or trans*, is an umbrella term that encompasses identities including cross-dressers; drag queens and kings; transvestites; bigender, genderqueer, and gender-variant people; and, what will be focused specifically on for the context of this paper, male-to-female and female-to-male transsexuals, who are described as “transgender women and men, respectively, who feminize or masculinize their bodies through hormone therapy or surgery” (Bockting, Miner, Romine, Hamilton & Coleman, 2013).
Prevalence of Anxiety in Transgender People It is also worth mention that anxiety and depression disorders are more prevalent among transgender people than cisgender (non-transgender) people. Transgender people have been recorded as being depressive at least three times as much as the cisgender population, and to have anxiety disorders almost twice as often (Budge, Adelson & Howard, 2013). In fact, the comorbidity of depression and other mental health disorders (very often anxiety) is cited to be common in transgender people (Rotondi, Bauer, Scanlon, Kaay, Travers & Travers, 2011).
Literature Review/Discussion
Percentages of Anxiety/Depression Among Transgender People Among all of the research studies available, percentages vary (and can vary vastly) as to rates of depression and anxiety among transgender people. These percentages vary mostly due to differentiations in each study’s measurement of depression and anxiety—for instance, some studies’ qualifications are any depression experienced in a lifetime, some are limited to recent depressive behaviors, and some refer to both (Rotondi et al., 2011). The Trans PULSE Project reported that approximately two thirds of female to male transsexuals (FTMs) exhibited depressive symptoms (Rotandi et al., 2011). In the Gómez-Gil, Zubiaurre-Elorza, Esteva,, Guillamon, Godáz, Cruz Almaraz, Halperin, & Salamero (2011) study, 39% of transgender people experience symptoms of depression and 94% of transgender people experience symptoms/possible symptoms of anxiety. Bockting et al., 2011, released a study saying that transgender people had a 44% rate of depression and a 33.2% rate of anxiety. Meanwhile, Budge et al.’s 2013 study reported 48-62% of transgender people suffer from depression and 26-38% of transgender people suffer from anxiety.
Significance of variations. The greatest standout for variations of percentages is the percentage given for possible symptoms and symptoms of anxiety in the Gómez-Gil et al. study, at ninety-four percent. As this percentage is drastically different from all the others, it must and should be taken into account that the definition for anxiety symptoms in this study also included possible anxiety symptoms, i.e. not necessarily confirmed diagnoses of anxiety. The other studies may vary due to the fact that some studies specify symptoms of anxiety/depression and some studies specify that the actual disorder must be present. So with varying definitions of anxiety and depression from study to study, there are bound to be slight differences with all the percentages reported in each study.
Transphobia, Its Repercussions and Its Role One of the major concepts that depression and anxiety in transgender people is correlated with is transphobia. Transphobia itself is a hatred or disrespect towards transgender people, and stemming from transphobia certain acts may be performed.
Transphobic acts.
Transphobic acts can include, but aren’t limited to, physical assault, sexual assault, verbal harassment, and the intentional misgendering of a person (calling an FTM “she” or an MTF “he”). These transphobic acts can cause or lead to larger amounts of “isolation, depression, anxiety, suicide, violent victimization, substance abuse, pregnancy, and school or job failure” in transgender people than cisgender peers (Health Risks, 2011). All transgender people report experiencing anywhere from a moderate to high amount transphobia in their lives (Rotondi et al., 2011). As one could imagine, these acts can be very damaging to a transgender person, to the point of causing mental distress and even …show more content…
disorders.
Enacted vs. felt stigmas. Another aspect to transphobia is enacted vs. felt stigmas. Enacted stigmas are concrete “experiences of rejection and discrimination”, while felt stigmas are the expectations of being reacted negatively towards, and the internal image or stigma that a transgender person forms as a result of these negative reactions when they occur (Bockting et al, 2013). Enacted stigmas due to the transphobic actions of others can often trigger internal stigmas. Studies have shown that the higher the levels of both types of stigmas are, the more psychological distress a transgender person feels (Bockting et al, 2013). Thus, the stronger the transphobia is against a person, the more mental stress they feel, in terms of both anxiety and depression.
Social Support for Transgender People Transgender people often, due to internal and external stigmas, isolate themselves from their peers. This isolation, in addition to lowering outlets available for social support, “can exacerbate depression, anxiety, substance use, and suicidality”, all common characteristics of an unstable mental state (Rotandi et al., 2011). Thus social support is a very important component in the mental health of FTM and MTF transsexuals. Higher levels of social support. Research has shown that the presence of high “social support, self-acceptance, and integration of minority identity” can improve a transgender individual’s stress levels despite transphobia (Bockting et al., 2013). When peers provide high levels of support for an individual, that individual’s identity isn’t questioned or prejudiced against, he or she fits into the community of his or her peers, and can begin to view himself or herself more positively. Family support. Transgender individuals, unfortunately, do not get as much support as their cisgender siblings do from family (Budge et al., 2013). This is unfortunate when you consider that there is a “protective effect of supportive families” in that transgender people who are accepted by their families are more likely to be defended by their families, and thus not feel as alone as those without support (Health Risks, 2011). There in fact are “potential negative health effect[s] of punitive and rejecting behaviors” by family members, henceforth depression and anxiety can be worsened when families reject a transgender person’s identity and refuses to support him or her (Health Risks, 2011). Low levels of social support. Meier, Pardo, Labuski, and Babcock (2011) have found that the lower social support (and thus perceived quality of life) a transgender person has, the higher his or her depression or anxiety is likely to be. This lack of social support can in some cases cause an individual to become distressed socially, due to lack of friends, lack of interaction, or other social dissatisfactions. These social stressors can serve as one explanation for the larger amounts of depression and anxiety in transgender people than cisgender people, who fit in more easily with their peers and are far more likely to have a larger amount of friends and stronger support base in those people (Budge et al., 2013).
Coping Methods and Mechanisms Another factor that strongly influences depression among transgender individuals are the types of coping that they choose to employ. Coping in general is something that can ameliorate mental stress. Avoidant coping is a style of coping that happens when someone tries to predict and inhibit emotional responses to what is causing the stress, while facilitative coping requires a person to “find alternate means to seek happiness”, such as going to friends, altering his or her actions, and learning new ways to deal with situations (Budge et al., 2013).
Harmful ways to cope. Avoidant coping can have a correlation with “higher levels of depression, trauma symptoms, mental health problems, and internalizing/externalizing problems for transgender youth” (Budge et al., 2013). Avoidant coping is a particularly harmful strategy for transgender people. The more a person relies on avoidant coping, the more anxiety, depression, and overall mental stress is reported by that person (Budge et al., 2013). Another interesting fact to note is that the further along a person is in their transitioning process, the less likely they were to report using avoidant coping. Therefore, the further along in time a person is, the less likely they are to report having anxiety or depression.
The Transition Process for Transgender People The transition process for transgender people can include starting hormone treatments—testosterone for FTMs and estrogen for MTFs—as well as sexual reassignment surgeries, where the genitals are reconstructed to match a person’s gender rather than biological sex. Before treatment, transgender people reported anxiety 61% of the time, and depression 31% of the time. Whereas after treatment, transgender people reported having anxiety 33% of the time, and depression 8% of the time (Gómez-Gil et al., 2011). People in the planning stage of transitioning who experience and deal with the consequences of transphobia, who have yet to begin any sort of medical advancements toward their transition, face an even higher instance of reduced mental health. Starting hormone therapy. Findings show that there is a relationship between hormone therapy in transgender people and lowered levels of emotional disorders and adverse mental effects (Gómez-Gil, et al., 2011). In fact, the longer of a period of time an FTM transsexual is on testosterone therapy, the lower his depression, anxiety, and stress levels (Meier et al., 2013). This is likely due to the fact that the longer an FTM spends on testosterone, the greater the amount of social support that he indicates he receives (Meier et al., 2013). This social support, as discussed earlier, is an integral part of a transgender person’s self-acceptance and ability to view the world in a positive way. Not only does social support increase with the duration on hormone therapy, but so does quality of life, according to Rotondi et al.’s 2011 study. Sex reassignment surgery. Sex reassignment surgery consists of using the sexual organs that a person already has to construct a neophallus and testicles, or a neovagina and neoclitorus, for FTM and MTF transsexuals, respectively. Rotondi et al. (2011) say that post-operative transsexuals report lower depression than pre-operative transsexuals. The Gómez-Gil et al. study (2011) mentions that after treatment, transsexuals report that they have a higher quality of life than before surgery. This is likely due to the phenomena that people who “feel unattractive tend to have more social anxiety and to suffer mixed adaptive emotional disorders” (Gómez-Gil et al., 2011). This seems to indicate that hormone therapy in addition to surgery increases a person’s overall self-image, and increasing that self-image can lower mental distress and disorders. The further along a person is in his or her transitioning process, be it hormonal or surgical, the more likely he or she are to exhibit high hopes for his or her future (Budge et al., 2013). This is particularly important as high hopes for future indicate healing from and lessening of depression and anxiety.
Conclusion
Much research has linked being transgender to anxiety and depression disorders, and it is nearly impossible to refute the percentages that testify that transgender people face a higher likelihood of having one of these disorders than cisgender people. Causes possible for this phenomena may include the amount of family and social support received by a person, the amount of transphobia and stigma directed at a person, coping methods employed, and duration of hormones/progress along a person’s transition.
Facing and fixing the problem.
Though transgender people in present times face fewer emotional disturbances than transgender people did a mere ten years ago, the percentages are still very significant and very much higher than those of cisgender people (Meier et al., 2013). Prevention of depression and anxiety in transgender people should, according to Bockting et al. (2013), face the problems of “social structures, norms, and attitudes that produce minority stress for gender-variant people”, as well as providing peers with a better understanding and ability to support their transgender friends, and perhaps most importantly, an increased access to “mental health and social services that affirm transgender identity and promote resilience.” This seems like a hefty task, to attempt to change social structures, but it will come in time. However, for the current time being, it would be in the best interest of the mental health of transgender people for resources to be made more widely available to seek therapy that reinforces identity and mental health, as well as promoting the education of cisgender people in a way that they would be able to understand and support transgender
peers.
References
Bockting, W. O., Miner, M. H., Romine, R., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943-951. Retrieved from http://web.ebscohost.com/ehost/detail?sid=4f3a0b3a-8a05-4c26-8a2753aed5e3a4c5%40 sessionmgr11&vid=1&hid=11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=86141441
Budge, S. L., Adelson, J. L., & Howard, K. S. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81(3), 545-557. Retrieved from http://web.ebscohost.com/ehost/detail? sid=1cf4e51a-9232-4115-af040a9575eb5412 %40sessionmgr14&vid=6&hid=11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2013-04448-001
Gómez-Gil, E., Zubiaurre-Elorza, L., Esteva, I., Guillamon, A., Godáz, T., Cruz Almaraz, M., Halperin, I., & Salamero, M. (2011). Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology, 35(5), 662-670. Retrieved from https://www.researchgate.net/publication/51660913_Hormone-treatedtranssexuals_ report_less_social_distress_anxiety_and_depression?ev=srch_pub
Health risks and needs of lesbian, gay, bisexual, transgender, and questioning adolescents position statement. (2011). Journal of Pediatric Health Care, 25(6), A9-A10. Retrieved from http://web.ebscohost.com/ehost/detail?vid=5&sid=1cf4e51a-9232-4115-af04-0a9575eb5412%40sessionmgr14&hid=11&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2011-24613-005
Meier, S., Pardo, S. T., Labuski, C., & Babcock, J. (2013). Measures of clinical health among female-to-male transgender persons as a function of sexual orientation. Archives of Sexual behavior, 42(3), 463-474. Retrieved from http://web.ebscohost.com/ehost/detail? vid =5&sid=1cf4e51a-9232-4115-af040a9575eb5412%40sessionmgr14&hid=11&bdata= JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=psyh&AN=2013-01063-001
Rotondi, N. K., Bauer, G. R., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and Risk and Protective factors for depression in female-to-male transgender Ontarians: Trans PULSE project. Canadian Journal of Community Mental Health, 30(2). Retrieved from http://cjcmh.metapress.com/app/home/contribution.asp? referrer=parent&backto=searchcitationsresults,1,1;