Depression and Suicidality Case Studys in Male-to-Female (MTF) Transgendered Indviduals

Psychiatric stress is associated with gender based identity issues. Specifically, this blog focuses on clinical depression and suicidality. Reporting Intervals for a study conducted by Nuttbrock et al included the following: Early adolescence (ages 10 through 14), Late adolescence (ages 15 through 19), Early adulthood (ages 20-24), Young adulthood (ages 25 through 29), Early middle-age (ages 30-39), and Later middle age (ages 40-59). The Life Chart Interview (LCI; Lykestos, et al., 1994) was given to respondents to gather data aimed at measuring changes in social relationships and psychopathology.  Psychiatric effects traced to gender abuse of Transgenderists was documented and analyzed. This population was chosen for many reasons by Nuttbrock some of which include the following: A fundamental sense of awkward incongruence with ones anatomic physiology and the resulting emotional and psychological distress that results from such.

 Additionally, many transgendered individuals are targeted victims of hate crimes and gender abuse. Physical beatings and verbal taunts by people ranging from loved ones and family members, to coworkers, strangers, and law enforcement officials occur when the expected societal norms are not seen as being upheld. Heterosexual members in society apparently resent the Transgenderists lifestyle because it does not follow the conventional customs and practices of society at large.  

Transgender Developmental Domains

Transgenderists universally report experiencing incongruence between the “internalized gender” versus their sex assigned at birth. In America cultural norms and societal expectations dictate the customary roles men and women find themselves charged with upholding. Perhaps more often than not it is easy and “natural” for little boys and little girls growing up in America to adopt the behavioral attitudes modeled by the majority within society and reflect them back and transmit these shared beliefs and customs as men and women over generations. There is a measurable population of Americans for whom such customs and societal expectations fail to contain yet at the same time seemingly enslave. It is customary in the west to pronounce gender at birth based solely on the anatomy of the baby. If the baby is born with a penis he is considered a male. If the baby is born with a vagina she is considered female. The gender assignment is a decision is made at birth by medical professionals and all resulting documents will clearly list the assigned sex of the baby forevermore.

Many developmental domains are significantly impacted when gender assignment results in incongruence as the person travels along the lifespan continuum.  Specifically, social, physical, cognitive, and sensory perception domains undergo unique stress and challenges for the transgendered person. One MTF Transgenderist named Virginia said, “Gender is between my ears not between my legs” (as cited in Prince, 2005, p. 30). Actualizing a transgendered-identity means living outside of and apart from the customary norms and expectations of society-at-large.

Studies by Goldberg, Matte, MacMillan, & Hudspith (2003) indicate that the transgender population as a whole seeks counseling in higher numbers than do members of the general population. Since the transgendered population is becoming a more outspoken and visible group it is important for professionals in the mental health field to become more informed and sensitive to issues concerning this group.  The term gender embraces cultural, social and psychological aspects that traits, norms and stereotyped roles of men and women to embrace within society (Gilbert &Scher, 1999).  However, a population defining itself as transgender does not fit neatly into the pre-packaged conceptualizations of western society and as a result experiences many unique challenges, stressors and perhaps strengths as a result of nonconformity. The scope of this paper specifically addresses MTF transgendered people and does not address female-to-male, cross dressers, pre and post operative transsexuals, transvestites, and many other variants found in nontraditional gender identities.  Anyone interested in the full spectrum of gender bending identity constructs can turn to research by Caroll, Gilroy, & Ryan (2002) for in-depth definitions and specificity.

The MTF person often desires to be understood and accepted by coworkers, friends and family members without negative events informing them they are wrong. The coming out process is a one step of many that allows the MTF person to feel as though they are closer to arriving at their own true identity (Devor, 2004; Gagne et al., 1997).  Further, there are four major themes inherent within this specific population identified by Gagne. Gagne details the parts of the coming out process that include finding names for what the individual feels, learning others share these feelings, overcoming fear of negative reactions, and coping with their own nontraditional expression of gender identity.

During adolescence many Transgenderists experience the onset of identity problems beginning at puberty. Developmentally speaking, an identity cloaked in confusion over being at odds with the societal majority and dominant norms and values may lead to higher levels of emotion distress. The study by Nuttbrock et al., revealed that clinical depression was found in MTF’s at a rate that is 54.3% higher than that of the general population. Further, lifetime suicidal ideation amongst MTF’s was 53.5% than results of the general population. In other words, it appears as though psychiatric distress along the lifespan is a very high amongst the MTF population; and research by Nuttbrock et. al., indicates it is three times higher than the general population. That said, it is important to note that further research about the prevalence and impact of gender related abuse declines over the course of a lifetime but is higher during early and late adolescence. It is possible that mental health professionals will encounter MTF’s seeking therapy due to difficulty in the work environment. A number of unique workplace challenges, interventions and specific accommodations need to be provided for Transgenderists. Anti-discriminatory laws and the legal duties employers face to ensure safe workplaces may bring MTF’s into a therapeutic alignment with a mental health worker.

 A study in 2003 by Minter & Daley proved that misperceptions and fears employers and coworkers have with Transgenderists in the workplace leads to complaints, a lack of collaboration, negative consequences, hostility, and isolation among other problems. The study showed that as high as 50% of MTF report experiencing workplace discrimination mostly while in a “trans” status that occurs after coming out at work. Of particular interest to counseling psychologists are links between a hostile or discriminatory workplace environment and resulting psychological distress for the MTF client (Harrell, 2000; Williams & Williams-Morris, 2000).

Research study participants expressed expressing relief and empowerment during the transitional phase and coming out at work (Budge, Tebbe, & Howard, 2010). One respondent named Carla felt powerful after the initial awkwardness of hormone therapy and the resulting emotions and growth of breasts. She was able to have a positive experience in the workplace after transitioning. Another respondent named Gina detailed a negative reaction by her coworker after she transitioned. Her former partner at work refused to continue working with her and Gina was told there was nothing she could do after she contacted Legal Rights. Gina decided to “keep her mouth shut” and put it behind her in order to create a space for a future better situation.   

  Therapeutic support is particularly helpful especially during the middle phase of transitioning at work. Rebecca details how the availability of family, friends and romantic partners helped her cope through her transition. Additionally, the guided support Rebecca received from her counselor allowed her to use medical reasons to explain to her employer how a transfer within the organization would best accommodate her new gender-identity. Rebecca was moved from a hot kitchen position into a retail position selling women’s accessories that was opened up just for her.

 Tina describes becoming an “entirely different person” expanding her social networks and being able to truly open up through a positive workplace experience and coworker acceptance. Alex coped at work by not asking for anything unreasonable and continuing to ask for things that were reasonable regardless of anticipated complications along the way. Jody began a new job after she transitioned and was the only woman on an entirely male crew. Jody was worried about fitting in but was reassured by her boss that any harassment along the way would be immediately stopped. Jody worked for a company with a very stringent anti-harassment policy.

 Another of the participants in the Budge, Tebbe & Howard study reported a severely negative workplace reaction to her MTF status. Erin’s status as a transgender was revealed to coworkers by her friend. Name-calling, verbal abuse that included using the former male name, property destruction, physical and sexual assaults took place. A group of males from Erin’s workplace attacked and sexually assaulted her which resulted in a terrifyingly brutal experience. Erin had long lasting psychiatric distress.

Jody believes she had trumped up charges leveled at her in the workplace which led to her being fired. Jody stated that her employer’s reasons for termination did not make sense and was later informed by the legal department that she experienced a classic case of workplace discrimination. However, since Jody did not have the financial resources to pursue a legal case against her employer she never initiated a legal remedy. Robin described a tightening in occupational prospects in areas of customer service, closely working with people face-to-face, and working with children. Robin surmises that the image she projects is not one that too many companies feel comfortable representing. Many of the research participants gave detailed accounts of problems revolving around discriminatory bathroom practices at work. For example, many MTF’s had experienced complaints when attempting to use the bathroom  assigned to their new gender. Some MTF’s do not feel safe and experience fear when forced to use the bathroom assigned to their biological sex. Other participants who never experienced stereotypical gender discrimination as white males were hurt when treated as “dumb blondes” after transitioning. A former blond, white, professional male who was highly respected before transitioning explained that after he transitioned he experienced placement into a “ subclass” of women who are at “the bottom of the barrel.” Most of the study participants expressed interest in activism through public awareness and education. Further agency included lobbying for policy change including getting gender identity added as a protective status in union contracts. Promoting equality, safety, and job security are issues of significant importance within the transgender community.

Correlating Major Depression and Suicidality with Gender Abuse

It is reasonable to assume that psychopathology is not a universal trait that manifests or defines childhood. Rather, it is reasonable to hypothesize that early psychiatric distress amongst the transgendered community results from abuse that is gender related. In other words, something occurs early on in the lifespan of MTF’s that leads to this developmental explanation of depression and Suicidality being higher in this population. That said, an empirical and accurate pinpointing of such a causal correlation remains elusive as many confounding variables remain unaccounted for.  Additionally, each client is a subjective case- study in the differential impact of gender abuse as well as different manifestations of psychopathological symptoms. Said differently, no two case-studies are ever exactly the same and each person’s unique biophysiopsychological make-up is different. Any resulting psychiatric distress will present somewhat uniquely as a result.  It seems from Nuttbrock’s in depth clinical studies that, indeed, there is a causative correlation between the early onset of psychiatric distress and gender abuse experienced by MTF’s in early adolescence (Nuttbrock, 2002).  Future research is necessary to clarify the differences of psychiatric distress and resulting effects of such amongst MTF persons. Presently, results are murky from Nuttbrock’s research in that rates of depression seem to decline while rates of suicide remain strong for the middle-aged and beyond respondents. As MTF’s move along the lifespan continuum the frequency and prevalence of gender-related abuse declines. One hypothesis of Nuttbrock et al is that as MTF’s age they acquire more social and emotional networks that have a buffering effect against the onset of clinical depression. Some techniques include behavioral routines and choices aimed at limiting exposure to the lethality of abuse by condemners (Nuttbrock et al., 2010). The notion of a “dose-response” is cited in the work of Kleinbaum, Kupper and Morgenstern (1982) whereby correlating amounts of gender abuse are equal in proportion to respondents’ causation and presentation of clinical depression and suicidal ideation.

Shifting the Paradigm for Transgender Health

The former medical model; a disease based model, viewed gender based identity issues as a type of psychopathology. In other words, the medical model holds that straying from the expected societal course of heterosexuality is a deficiency of sorts, and nothing less than a condition to diagnose, and respond to with medical interventions aimed at curing the condition. In fact, the DSM-III listed homosexuality as a mental disorder. The present DSM-IV was revised and being a homosexual is no longer considered psychopathological. Today an identity-based model is preferred which is a transgender-health based model; therefore differing from the former disease-based medical model (Boxting, W.O., 2009).

Conclusion

Moving from a disease-based model to an identity-based model (Boxting, W. O., 2009) in dealing with transgendered individuals is necessary in order to provide effective therapeutic interventions and techniques. Validating the expression of the transgendered identity may help raise societal awareness and heighten sensitivity to this unique population. By protecting the status these people we can improve their lives across the developmental lifespan continuum. Since research shows that MTF’s experience a disproportionate rate of clinical depression and suicidal ideation we have an ethical duty to raise our own awareness as mental health practitioners so as to best alleviate the resulting symptomology within this group seeking treatment. Further, we can guide these clients into self-agency, and introduce them to social networks and support groups to ease their transition; especially in the workplace where gender-identity abuse and discriminatory practices remain high. Empirical research shows us we need a paradigm shift and more research and focus so as to provide the best therapeutic remedies we can. Transgendered people have different experiences along the developmental domains than their cohorts and more investigative research and study may allow them  to transition more freely and embrace rather than shun who they really are and avoid early psychological distress and resulting maladaptive schemas that bring them to therapy.