‘Where does [my] anxiety come from? The world!’ Trans and gender diverse mental health

Trans and gender diverse people in the UK are in the midst of a national healthcare crisis. The NHS currently has a maximum waiting time for non-urgent referrals of 18 weeks, yet current waiting times for trans and gender diverse patients seeking support and gender related care are between 4-5 years (GIC, 2021). In October 2021, the London Gender Identity Clinic (GIC) reported 9,667 patients on their waiting list. Long waiting times and difficulties in accessing trans health care has been connected with anxiety, sleep problems and distress.

Recent statistics show that trans and gender diverse mental health is negatively impacted by everyday transphobia, negative media attention and lack of access to adequate healthcare. Studies have found that 66% of trans participants have reported using mental health services outside of gender-related healthcare. Within trans and non-binary populations research indicates increased levels of depression, anxiety, self-harm and attempts of suicide compared to LGB people.

To address these concerns, the University of Oxford has been funded to develop an online resource that highlights the healthcare experiences of trans and gender diverse youth aged 13-35 (n=50) across England and Wales, as well as parents of trans and gender diverse youth. Among many other topics, trans and gender diverse participants discussed the key issues impacting their mental health and their experiences of prescribed medication.

Key mental health concerns for trans and gender diverse youth

Gender identity and mental health

The trans and gender diverse young people we spoke to were keen to emphasise the nuances between their gender identity and mental health needs. Some young people felt that gender dysphoria¹ contributed to poor mental health, in particular, the relationship they had with their body. Feeling an incongruence between their body and gender sometimes caused distress: 
 
“Gender dysphoria takes a huge toll on mental health. It’s really hard to get up every morning and have to look at your body and know that it’s not right, and it won’t be for a long time.” (trans male, 21)

However, some young people were also keen to separate out gender dysphoria from other things in their life causing them distress. Our participants found it frustrating when health professionals automatically assumed a link between the patient’s gender identity and poor mental health and didn’t listen to their views:

“I went to IAPT²and then went to Crisis³, and she was like, “It’s because you’re trans you’re stressed,” and I was like, “No”. However, she wouldn’t take it for an answer. […] Life’s stressful because I’m trans but it doesn’t mean that [being trans is] causing my mental health issues right now. There are other things that are.” (trans male, 20)

Participants also described their GP’s confusion about how best to support trans and gender diverse patients due to conflating gender identity and mental health needs:
 
“I went to my GP about getting referred to the gender clinic and it was kind of all good because I went purely for that reason, to be referred. And he kept sort of looking through my notes and just bringing up the fact that I had depression and he just kept trying to like prescribe anti-depressants and it took me like it took about a good, I don’t know 20 minutes for him to actually be like ‘no, I just want you to refer me to the clinic’.” (trans male, 23)
 
Elsewhere we have described how healthcare professionals often lack training in, and understanding of trans identities, and healthcare options.

Managing other types of stress

Our young people talked about different layers of stress that they were experiencing. This included stresses from work and/or study or school pressures, as well as friendship, family and relationship worries. A few young people also talked about the impact of isolation and loneliness. Young people also talked about discrimination and prejudice they experienced generally, particularly misgendering. Transphobia in the media was reported as a significant contributor to poor mental health.
 
“It’s definitely transition and dysphoria and misgendering have given me levels of anxiety and suicidal thoughts that I never had before and never thought that I would” (trans female, 25)
 
“I see in the news a lot of really transphobic just hateful articles and messages coming from everywhere, you know, right wing and left wing newspapers, you know I expect it from right wing, you don’t expect it from the left wing. Just seeing that shit everywhere does take the toll on you and it does make you feel low, it does make you feel just like alone and isolated so I do see a therapist and kind of talk around that stuff” (trans male, 22)

Lack of support and waiting

The trans young people repeatedly talked about the negative impact that waiting for NHS gender identity services had on their mental health. They spoke about the length of time and lack of support they felt.
 
“Not having the opportunity of treatment or having the opportunity of treatment being so severely delayed makes it seem like there’s no possible way out. Or if there is a way out that its years away. It just makes things even harder to deal with than they are already.” (non-binary, 23)

Prescribed medication for depression and anxiety

Young people talked about the use of prescribed medication to tackle depression and anxiety such as anti-depressants, SSRIs, and beta-blockers. Many described this as a positive step often alongside other forms of support, whilst others had mixed experiences of medication. Some young people were not sure that medication was suitable for them, while others had tried different types of medication. A few young people highlighted negative side effects of prescribed medication for mental health.
 
“I think I was 19 when I first started taking antidepressants. And I was put on them after just one appointment with my GP. I think, at the time, I just wanted a quick fix, which it wasn’t that. But I wasn’t even offered counselling or anything which really, I should have been.” (trans male, 23)
 
“I’ve also been prescribed beta-blockers for anxiety and some type of antidepressant. I can’t remember the name of. So, the beta-blockers do help quite a bit with managing my anxiety with the physical symptoms of it and the antidepressants so far seem to be doing that, I think.” (genderqueer, 19)

Prescribed medication for hormone therapy

 One of the primary forms of mental health support for trans and gender diverse participants was seeing their bodies change through intervention such as hormone therapy. For trans men and transmasculine people this is involves being prescribed and taking testosterone as part of masculinising the body. For trans women and transfeminine people this involves being prescribed and taking oestrogen, and sometimes testosterone blocking medication as part of feminising the body. Young people talked about their relationship with their bodies and how this related to their mental health:
 
“Because the mental health system is not the best at the moment in the NHS. I haven’t had much luck with it. But being able to get on the [hormone] meds that I need and having that support network being around me and affirming me” (non-binary, 23)
 
”Seeing my body change I really actually started developing a subjectivity in relation to my body where I would look at it and I’d be like ‘okay this is making me feel good’ which is not something that had ever happened before" (trans male, 29)

Informed consent model

Many of the trans and gender diverse young people we interviewed want to see changes to how trans healthcare as a system is ultimately structured. Young people want a healthcare system built less around gatekeeping and more around partnership and collaboration between healthcare professional and patient.
 
Experts have discussed the informed consent model and advocate a shift away from the pathologisation of transgender identity as a disorder and a move towards viewing transgender as another identity in health care. Similarly, trans affirming groups have been calling for an informed consent model, which centres the patient’s healthcare needs flexibly without gatekeeping treatments based on identity. The informed consent model removes unnecessary barriers to hormone therapy, including restrictions specifying prolonged mental health evaluations and real life tests (i.e., living fulltime in one’s self-identified gender) to obtain hormone therapy that have long been embedded in existing standards of care:
 
“I think a lot of mental health struggles would be alleviated if just the entire system for getting medical treatment was easier in the first place like if you’re having to go to the therapist because waiting years for a GIC appointment is just too much” (trans female, 23)
 
This research forms part of two new modules on trans and gender diverse healthcare experiences which were published on www.healthtalk.org in 2022.

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