Transphobic rejection: an ineffective and dangerous “treatment”

When discussing transgender healthcare needs, I’ve previously covered the known health benefits of gender-affirming approaches such as social transition, puberty blockers, hormone therapy, and surgeries. The evidence for the efficacy of transition treatments is overwhelming, with clear improvements in dysphoric symptoms, body uneasiness, stress levels, depression, anxiety, overall mental health, quality of life, and social functioning. For these reasons, major medical organizations, including the American Psychological Association, American Psychiatric Association, American Academy of Pediatrics, American Association of Family Physicians, Endocrine Society, American Academy of Child and Adolescent Psychiatry, American College of Obstetricians and Gynecologists, and World Professional Association for Transgender Health, recognize the importance and necessity of affirming care for trans people.

However, this strong expert consensus is evidently unpersuasive to a number of people who engage with my work. I still frequently receive comments declaring that trans-supportive care is an inappropriate approach, and that trans people should not be accepted in society or facilitated in living as their genders. Often, commenters state that trans people should simply attempt to live as their assigned sex, or should obtain some unspecified therapy to assist them in rejecting their known gender identity.

What’s being proposed here certainly does not constitute a coherent “treatment” in any sense, and is generally lacking in any details beyond the unwavering insistence that trans identities should be rejected. But what if we were to evaluate this as if it were a treatment? I’ve spent plenty of time examining the measurable results of acceptance and affirming care for trans people – so how does rejection stack up in comparison? What outcomes can be expected in trans people’s lives when they’re pushed to live as their birth sex, and their genders are rejected and denied by those around them?

This, too, has been studied extensively, and the results are generally consistent. Rejection by family, community, and society is linked to a greater likelihood of negative life outcomes. According to the 2015 U.S. Trans Survey (James et al., 2016), which received answers from 27,715 transgender respondents, those with unsupportive families were more likely to be unemployed – only 52% of trans people with unsupportive families had a job, compared to 65% of those with supportive families. Respondents without family support were also far more likely to have been homeless at some point: 45% of those in this group had been homeless, versus only 27% of those who were supported by their family.

Family rejection has also been associated with a variety of severe impacts on trans people’s health. While 52% of trans people who were supported by their families said they were in very good or excellent health, only 38% of those who were rejected by their families said the same. 50% of respondents with unsupportive families said they experienced serious psychological distress, compared to 31% of those who were supported. A rejecting environment can have potentially deadly effects: only 37% with supportive families reported attempting suicide, whereas 54% of those without family support had attempted suicide. Experiencing anti-trans “conversion therapy” or “reparative therapy” was also a serious risk factor – those who underwent such treatments were more likely than those who didn’t to experience homelessness (46% vs. 29%), serious psychological distress (47% vs. 34%), or a suicide attempt (58% vs. 39%). A study of the data from the previous National Transgender Discrimination Survey in 2011 also found that respondents who were subject to higher levels of family rejection were increasingly likely to engage in substance abuse or attempt suicide (Klein & Golub, 2016).

Additional studies have confirmed that a lack of support is linked to greater suicidal ideation among trans people (Tebbe & Moradi, 2016), and experiences of discrimination are more likely to lead to suicidal ideation for trans people with low levels of support from others (Trujillo, Perrin, Sutter, Tabaac, & Benotsch, 2017). Another study of 865 trans participants found that social support had a protective effect against depressive and anxious symptoms (Pflum, Testa, Balsam, Goldblum, & Bongar, 2016). Low levels of social support have also been associated with self-harming behaviors in trans people (Claes et al., 2015), as well as reduced life satisfaction and quality of life (Davey, Bouman, Arcelus, & Meyer, 2014), and even a lower level of physical activity (Muchicko, Lepp, & Barkley, 2014).

Transgender youth are especially vulnerable to the effects of rejection by family and peers. In a survey of trans youth in Ontario, those with lower levels of support from their family were less likely to be in good mental health, less likely to have high self esteem, less likely to have adequate housing, and less likely to be satisfied with life (Travers et al., 2012). Another study of trans youth at Children’s Hospital Los Angeles found that a lack of parental support was associated with depressive symptoms and lower life satisfaction (Simons, Schrager, Clark, Belzer, & Olson, 2013). Low parental support has also been linked to a greater likelihood of unsafe sex among trans girls (Wilson, Iverson, Garofalo, & Belzer, 2012).

In comparing the effects of acceptance versus rejection on trans people’s health and well-being, the evidence is clear and consistent. Rejection simply makes trans people’s lives worse among almost any measurable outcome, while acceptance largely prevents these negative impacts. In light of this, it makes no sense to claim that denying our genders is the most suitable approach to transgender identities. This would require claiming that it’s somehow better for us to experience homelessness, depression, anxiety, stress, low self-esteem, self-harm, substance abuse, unsafe sex, suicidality, and poor quality of life – and worse for us to be given the support that makes all these negative outcomes less likely. Truly caring for trans people means believing that we deserve better in our lives, and the available evidence strongly constrains what “better” looks like: Wanting to help us requires wanting us to be accepted as who we are. ■

References

• Claes, L., Bouman, W. P., Witcomb, G., Thurston, M., Fernandez-Aranda, F., & Arcelus, J. (2015). Non-suicidal self-injury in trans people: associations with psychological symptoms, victimization, interpersonal functioning, and perceived social support. Journal of Sexual Medicine, 12(1), 168–179.
• Davey, A., Bouman, W. P., Arcelus, J., & Meyer, C. (2014). Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls. Journal of Sexual Medicine, 11(12), 2976–2985.
• James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
• Klein, A., & Golub, S. A. (2016). Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health, 3(3), 193–199.
• Muchicko, M. M., Lepp, A., & Barkley, J. E. (2014). Peer victimization, social support and leisure-time physical activity in transgender and cisgender individuals. Leisure/Loisir, 38(3-4), 295–308.
• Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. (2015). Social support, trans community connectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 2(3), 281–286.
• Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. Journal of Adolescent Health, 53(6), 791–793.
• Tebbe, E. A., & Moradi, B. (2016). Suicide risk in trans populations: an application of minority stress theory. Journal of Counseling Psychology, 63(5), 520–533.
• Travers, R., Bauer, G., Pyne, J., Bradley, K., Gale, L., & Papadimitriou, M. (2012). Impacts of strong parental support for trans youth. Ontario, CA: Trans PULSE Project.
• Trujillo, M. A., Perrin, P. B., Sutter, M., Tabaac, A., & Benotsch, E. G. (2017). The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. International Journal of Transgenderism, 18(1), 39–52.
• Wilson, E. C., Iverson, E., Garofalo, R., & Belzer, M. (2012). Parental support and condom use among transgender female youth. Journal of the Association of Nurses in AIDS Care. 23(4), 306–317.