So, it's possible that while you were reading last Wednesday's post on the difference between being transgender and having a mental illness, you stopped for a second and thought "but wait a minute! I'm transgender and I do struggle with a mental illness! How do I fit into this equation?"
Or perhaps you're not trans yourself, but you have a friend who has recently come out to you as transgender, and who has struggled with a mental illness in the past, and you wonder if the two may be connected. Maybe you're a parent, worried about your transgender child who deals with anxiety, or depression, or an eating disorder, and you're not sure which issue to address first.
While it's true that gender dysphoria itself is not a mental illness, we do need to recognize that, unfortunately, many trans folks do live with anxiety, depression, and/or eating disorders. Sometimes these issues are a direct result of the way trans folks are treated in their day-to-day life, and sometimes they're the mind's way of dealing with gender dysphoria prior to coming out and transitioning.
Social anxiety is possibly the most prevalent disorder found among transgender folks, with studies in 2005 and 2010 showing that 55% of transgender people experience high levels of anxiety, compared to only 6.8% of the cisgender population. The American Psychiatric Association's 2012 recommendation for access to care for transgender people helps us understand this huge disparity:
Transgender people may find themselves living in constant fear of verbal or physical harassment. While a healthy mind can deal with this kind of pressure for short periods, over time this perpetual sense of danger is likely to develop into a debilitating form of social anxiety.
Depending on personality and genetics, some people are more prone to depression than anxiety, or may suffer from a combination of the two. A 2015 study from the Harvard School of Public Health found that, of transgender people between the ages of twelve and twenty-nine, 50.6% were diagnosed with depression and 17.2% had attempted suicide. As we come to understand depression in the transgender community more accurately, it's become clear that the major cause is what's referred to as "minority stress;" that is, "stressors induced by a hostile, homophobic culture, which often results in a lifetime of harassment, maltreatment, discrimination and victimization." The good news, then, is that as social relations and culture change over time, negative attitudes toward transgender people may be reduced, which will then reduce the stressors which trigger anxiety and depression.
Another fairly common disorder found in the transgender community revolves around food. Though, as we've already seen, gender dysphoria and body dysmorphia related to eating disorders are very different, it is possible to suffer from both at the same time. In a 2015 study of students at 223 different universities, it was found that "Transgender students were more than four times as likely to report an eating disorder diagnosis as cisgender heterosexual women," who are generally the focus of eating disorder studies. The reasoning behind this discrepancy is fairly straightforward--transgender women feel the same pressure to stay thin that cisgender women feel, while transgender men often realize that keeping a low body weight represses secondary sex characteristics and menstruation. For many trans teens who aren't allowed to transition, it may feel like disordered eating and excessive exercise are the only ways to make their body more masculine or feminine.
It's not surprising, then, that alongside trans-inclusive mental healthcare, the ability to physically transition has had the most positive effect on trans folks suffering from anxiety, depression, and eating disorders. Study after study has confirmed that access to hormone therapy has had a positive effect on the mental health of transgender patients. One 2012 study looked at a sample population wherein about two thirds had undergone hormone therapy, while the remaining third had not, and found that individuals who had not begun hormones experienced approximately 30% higher levels of anxiety and depression. Two more recent studies, one from 2013 and one from 2014, looked at a representative population of transgender people before hormone therapy, at one year on hormones, and then after any desired gender confirmation surgery. The results found an even greater reduction in disordered symptoms, especially in symptoms of anxiety, after the start of hormone therapy, and what's more, after twelve months on a hormone regimen, transgender patient's scores on symptom checklists resembled the scores of the general population! Additional studies focusing on levels of cortisol, a stress hormone, found that prior to hormone therapy trans people experienced higher perceived stress, while after twelve months of cross-sex hormones their cortisol levels came down and fell within the normal range.
So while it is true that the transgender community suffers from mental illness at a higher rate than their cisgender peers, we can take comfort from the knowledge that these disorders are understood, treatable, and above all, that they do not undermine our gender identities. Just because you may deal with depression does not mean your dysphoria is a moot point; just because you struggle with anxiety doesn't mean that your fear of harassment isn't real; just because you're recovering from an eating disorder doesn't mean you're not allowed to ask for help when it comes to gendered expectations surrounding body image. If we take nothing else from these studies--if we ignore the positive effects of trans-inclusive mental healthcare and access to hormone therapy--we must at least recognize that our mental illnesses don't render our gender identities insignificant. Let's hope that as more research is done we'll see positive advances in trans-inclusive treatment in the medical community, and continued movement towards legislation to protect LGBT folks from the social stigma that triggers these disorders.