Trans adults have improved mental health and less suicidal thoughts when their identification documents reflect their identified gender, new research shows.
The findings* published this week in The Lancet Public Health journal are based on the results from a survey of over 20,000 American trans adults.
The authors note that the survey only questioned respondents at one time point, making it difficult to confirm whether lack of gender-affirming IDs caused psychological distress or the other way around. It is possible that trans people suffering from psychological distress might find it harder to obtain IDs. However, a previous Canadian study found that having at least one document showing a trans person’s preferred gender marker was associated with fewer suicidal thoughts and suicide attempts, and previous research has found that mental health risks in transgender adolescents are reduced when their preferred name is used socially.
“Our results suggest that governments and administrative bodies can play an important role in helping to reduce psychological distress for trans people, simply by making it easier to access identity documents that reflect their identity,” says Dr Ayden Scheim from Drexel University, USA.
Of the 1.4 million Americans who identify as transgender, over half are estimated to have clinical depression, compared to around 30% over a lifetime in the general US population, while 31% to 41% attempt suicide at some point during their lives, compared to less than 9% generally in the US.
These mental health disparities can be attributed in part to a lack of recognition and acceptance of trans people’s identified gender. Lack of gender-concordant official documents can prevent access to services such as healthcare, education, and employment, and increase exposure to verbal harassment and violence.
To explore the impact of access to IDs on psychological distress, suicidal thoughts and suicide attempts, researchers analysed data from 22,286 trans people, who were surveyed in 2015. Respondents were asked whether all, some or none of their IDs - including birth certificates, passports and driving licences - listed their preferred name and gender marker. Psychological distress was measured using a validated scale with a score between 0 and 24, with 13 or greater indicating serious psychological distress. To assess respondents’ suicide risk, they were asked whether they had seriously considered suicide in the previous 12 months, whether they had made any plans to kill themselves and whether they had attempted suicide.
To ensure that the analysis was able to pick up any association between mental health and access to updated IDs, the authors of the current study adjusted the results to account for other variables that could contribute to psychological distress and suicidal thoughts - such as age, ethnicity, medical transition status and years living full-time in the identified gender.
The results found that 45.1% of respondents (10,288 out of 22,286) had no IDs with their preferred name and gender marker, 44.2% (9,666/22,286) had some ID that matched their name and/or gender, and only 10.7% (2,332/22,286) had their preferred name and gender on all their documents. The authors weighted the sample to reflect the age and ethnicity of the US population, although they note that trans demographics may not mirror broader US population demographics.
Those with all gender-concordant IDs had a 32% lower prevalence of serious psychological distress than those with no updated documents. They were also 22% less likely to have had suicidal thoughts in the past year and 25% less likely to have made plans to kill themselves. Those with some updated IDs had smaller reductions in distress and suicidal thoughts (e.g., 12% reduction in distress). The results did not indicate an association between access to IDs and suicide attempts, once the authors had adjusted for other influences on mental health.
“When a trans person changes their gender on their official documents, it can be a critical step towards gaining social acceptance and legal recognition, and our findings suggest that policy changes to support trans people with taking this step should be considered, in order to help improve their wellbeing, reduce their exposure to discrimination and reduce suicidal thoughts,” says Professor Greta Bauer from Western University, Canada.
The authors note that other variables not covered in the study may mediate psychological distress, for example access to social support.
Writing in a linked Comment,** lead author Dr Monica Malta (who was not involved in the study) from the University of Toronto says: “The cross-sectional study design prohibits causal interpretation of the identified relationships, and reverse causation is plausible—those with better mental health might be better able to navigate the difficult bureaucratic requirements to obtain gender congruent IDs. Even with those limitations, the large dataset and careful inclusion of potential confounders strengthen the study design. Thus, the authors’ findings support the need to increase the availability of and streamline the processes to obtain gender congruent IDs.”
* Scheim AI, et al. Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study. The Lancet Public Health, March 2020. DOI: 10.1016/S2468-2667(20)30032-3
** Malta M, et al. Gender-congruent government identification is crucial for gender affirmation. The Lancet Public Health, March 2020. DOI: 10.1016/S2468-2667(20)30054-2