Darker shades of pink: Having depression when you’re transgender

by Zinnia Jones — March 14, 2014

The past few years of my life have featured various events that repeatedly force me to update significant parts of how I understand myself. I used to see little purpose in life and no path forward for myself, until I created an ongoing open-ended project to direct my energies toward, and coincidentally slid into utter femininity in a matter of months. I’ve gone from coasting on the decades-long assumption that I was still a guy – just an extremely femme one – to realizing that no part of me bristles against womanhood. I thought I didn’t have any gender dysphoria, and medically transitioning was simply a matter of taking things from “good” to “even better”. Then I started HRT and gained the perspective to see just how awful, how suffocating, how unbearable things were before – and how it brought me to a place where I was finally a happy, functional person who truly loved life.

About that last one…

You’d think, after all this, I’d understand that things are always going to keep changing. I should realize by now that if I believe the current state of my life will persist forever, I’m almost certainly wrong. Many of my writings should be considered mostly obsolete for that very reason. They’re snapshots of a certain time in my life, not conclusions meant to persist for all eternity – and as more time passes, they’ll become more divergent from reality.

Still: I thought I had fixed this. I thought I had found the answer – the reason why I had felt so pervasively uncomfortable for all of my life, and the solution that did what nothing else could and actually made everything better. I thought I was in the clear to check that off as decisively handled.

I’m now having another one of those moments where I’m forced to realize: I was wrong. I was wrong about having fully understood the nature of my problems. And I was wrong about the extent to which transitioning could adequately address them.

 

1. How I experience dysphoria

For the most part, my dysphoria typically doesn’t feel like discomfort with the physical form of my body. My dysphoria feels like depression. I wasn’t aware of this similarity at first, because I didn’t yet have an understanding of what depression feels like. Other people had to tell me.

When I wrote “8 signs and symptoms of indirect gender dysphoria”, I aimed to offer a description of the emotional problems which I experienced prior to transition, and which went away after I transitioned – experiences that had also sometimes been relayed by other trans people. I did my best to convey how this felt for me:

• “I could force myself to get things done, but it would take a lot out of me. I would be irritable, snappish, annoyed by everything, and in anywhere from a mildly bad mood to a very bad mood almost every day.”
• “As a child, I would cry almost every day at the drop of a hat. Anything could trigger it – being even mildly reprimanded, getting a wrong answer on schoolwork, the sort of insignificant things that no one else around me ever cried so frequently about.”
• “A feeling of just going through the motions in everyday life, as if you’re always reading from a script.”
• “When I worked on things, there wasn’t any higher sense of eventually working toward anything.”
• “Nothing made me feel truly fulfilled, like I was accomplishing anything meaningful.”
• “I often wondered how other kids could just go about their lives, talking and laughing and being so calm and happy, like nothing was wrong.”

Many trans people told me that this article resonated strongly with them; some said it was as if they were reading what could have been their own journal. Others pointed out that there was substantial overlap between what I described, and the symptoms of depression. Some felt that this overlap was so complete, the article was not a meaningful description of dysphoria at all – one trans woman called it “frankly, bullshit”.

To show a connection between these experiences and gender dysphoria, I had to rely on one key point: that these issues were present before I transitioned, and they unexpectedly subsided once I began to transition.

So what does it mean when they come back?

 

2. The limits of my understanding

Before transitioning, I had concluded that these pervasive negative feelings were simply an innate aspect of my personality, and something I’d have to learn how to live with:

I figured all I could do was ignore it as much as possible and focus on whatever positives I could find – I gave up hope of ever truly fixing this.

So, having decided that this is just how I am, I didn’t think to consider whether these issues might be due to an actual, knowable cause like dysphoria or depression. Even as I developed a better sense of my gender, it didn’t occur to me that there could be a link between finding a more suitable identity for myself and resolving my emotional problems. I saw these things as two parallel lines, each progressing on their own path but never intersecting. I didn’t regard transitioning as a way of fixing my mood issues – of all the reasons I was driven to do it, this just wasn’t one of them.

So it came as a surprise when these two things began to interact: I started HRT in 2012, and almost immediately felt free of all the crushing negativity for the first time in my life. Thus, I learned to recognize dysphoria. I did not learn to recognize depression.

This would prove to be a major deficiency in my understanding of the problems I’ve faced. Around the end of 2013, I started experiencing what seemed like the same thing all over again:

• Being exhausted by everything, and irritable all the time
• Feeling unable to handle the basics of everyday life
• Becoming stressed to the point of crying at the end of every day
• Seeing no ultimate point to anything I did, and feeling it was all meaningless
• Wondering why I even had to be alive

Because I had previously associated these feelings with dysphoria, my first guess was that all of this had to be linked to gender-related factors. So that was where I started: Was it my recently-adjusted progesterone dose? Is it that I just haven’t had the right surgeries? I switched back to my previous dose – but the relief was only temporary. (Surgeries, obviously, are not quite so accessible or easy to experiment with.)

It just didn’t make sense – I didn’t understand why everything suddenly felt so horrible, even though very little had changed. I was starting to get scared. Things were fine before. What is this?

 

3. Looking beyond gender

My fiancée Heather has often provided a useful outside perspective on my issues. That just sounds really abstracted, though. The truth is, she’s the reason I realized I’d rather be someone’s girlfriend than their boyfriend. She was the first person to call me “she” all the time and make it feel normal, a simple fact of who I am. She started a new life with me, in a place where everyone knew me as a woman. She let me know that starting hormones would make me even more desirable in her eyes, not less.

Without her, much of my transition wouldn’t have happened with such efficiency, or happened at all. We’ve been together for nearly three years, and Heather knows me very well. She’s also struggled with depression throughout her life, and this provided her with some degree of insight into just what the hell was going on with me this time.

When she noticed I’d been miserable for weeks, and asked me what was wrong, I told her how all of this felt – how everything just seemed like too much, and I didn’t feel like I could handle it anymore, and I didn’t know why. It sounded familiar to her, and she raised the possibility of depression. I asked her: is this what depression feels like? She confirmed this. My next, even more desperate question: just how helpful is her medication?

 

4. Navigating healthcare as a trans woman

I only go to my gynecologist for HRT and the associated check-ups and blood monitoring. I’d have to find someone else for this new… thing. (I still wasn’t certain of how to name it, and I’d talk about it in terms like “this stuff” or “dealing with things”.) Before this, I actually didn’t have a regular physician, largely because I just didn’t want to deal with doctors. It’s not due to some arbitrary aversion – it’s because receiving appropriate and sensitive healthcare when you’re trans, even healthcare completely unrelated to transitioning, is a minefield.

Trans people have often found that when they seek care for any sort of illness, their doctors advise them to discontinue HRT regardless of whether their current health problem has any connection to this. Some of us don’t even get that far – one of my friends was unable to receive any medical attention for her asthma simply because her doctor refused to treat trans people at all.

This issue is more than anecdotal: in a national survey of over 6,000 trans people, 19% reported they had been denied service by a healthcare provider due to being trans. 28% had been harassed in a medical setting because they’re trans. And 28% also reported that because of disrespect and discrimination from providers, they delayed or avoided treatment when they were ill.

That may not be wise, but when cis people go to a clinic for a flu or a broken toe, they generally don’t have to worry about being turned away just because of who they are. We do, so seeking care can be a difficult thing to contemplate. When going to a new and unfamiliar doctor, we never know what kind of ignorance or hostility we’re going to face. It’s an alarming unknown.

So I went with the option that we already knew the most about. Heather’s family doctor had treated her depression and anxiety, and he knows that she’s queer – she told me of how she’d started crying in his office while talking about how her co-workers called her a “fag” every day. She’s never had problems with him. I’d also met him when we took our son for check-ups, and he was really friendly toward all of us. To me, he seemed like the best bet. Heather reassured me: “If he gives you any trouble, we’re all firing him.”

 

5. “Mild depression”

Outness is a risk factor for refusal of service: 23% of trans people who are out to their medical providers have been denied service, compared to only 15% of those who aren’t out. Nevertheless, I still listed my current medications on the intake form, and left helpful notes like “I am a transsexual woman (male-to-female)” in the “other information” section. I didn’t want to have to deal with any surprise issues if they only realized I was trans later on, nor did I want to see someone who would only be willing to treat me under the pretense that I’m cis.

Fortunately, all of this turned out to be a non-issue. Other than asking whether I was taking hormones under the supervision of a doctor and whether I’d had a blood test recently, the topic didn’t even come up. He asked how I was feeling, and I told him everything – the way that life had somehow become unbearable for no apparent reason, and the dread I felt at having to face every single day. And I made sure he knew that it wasn’t like this before, that transitioning had helped me more than I ever expected, that it really did make things so much better and I didn’t know why this was happening now.

He seemed to know exactly what I was talking about, even identifying the feelings I hadn’t yet mentioned: the monotony of everything, and the difficulty with finding the motivation to get started on almost any activity. Everything he said gave me the impression that he understood this well. He concluded that because this appeared to be a more recent and transient problem rather than a lifelong issue, it was likely a kind of “mild depression”.

We worked out a balance of which medication would be both affordable and effective for me, and ended up settling on his first recommendation – something he felt would give me more energy. “I take it myself”, he reassured me as he wrote the prescription.

 

6. Anything but trans

People widely regard being trans as an undesirable existence. Often, cis people just don’t want the people around them to be trans – whether this comes from a place of overt intolerance, or just pity and regret for the hardships we face. And trans people, sometimes to an even greater extent than cis people, have also been known to seek out any potential reason to conclude that they’re not actually trans and therefore won’t need to face expensive procedures and near-universal hostility from society.

This urge to avoid the possibility of transness manifests as a staggering variety of excuses and denials. The cis people around us, often our parents and relatives, may claim that our gender-related feelings can instead be explained as a product of:

• Childhood bullying
• Sexual abuse
• Negative experiences with other members of one’s assigned sex
• The influence of supportive therapists and other professionals
• Following a trend among a social circle
• Viewing pornography
• Homosexuality
• Unspecified “confusion”
• Demonic supernatural influences
• Low testosterone (for trans women)
• Traumatic brain injury
• Autism
• Depression

These are all things that trans people have actually reported hearing from various cis people, and this is not an exhaustive list. Given the prevalence of these creative explanations, trans people in search of reasons to doubt their own transness have ample opportunity to seize on them as well. But this fervent effort to locate any possible alternatives to transness extends beyond the poorly-informed folklore of laypersons. It’s also visible in the poorly-informed folklore of certain medical professionals.

 

7. Trans-negativity in medicine

Dr. Kenneth Zucker is head of the Gender Identity Service for children at Toronto’s Centre for Addiction and Mental Health. Under his direction, this program has subjected children to a form of reparative therapy to discourage them from being trans or questioning their gender. This includes taking away “girlish toys” like dolls from male-assigned children and encouraging more stereotypically masculine interests, an approach resembling the techniques of discredited “ex-gay” programs.

Zucker contends that cross-gender identification in children is driven by other issues not directly related to their gender, and calls their feelings “a ‘fantasy solution,’ that being the other sex will make them happy” – in other words, a misguided answer to a separate problem in their lives. He posits that their desire to live as another sex is instead largely rooted in family issues:

First, he thinks that family dynamics play a large role in childhood GID—not necessarily in the origins of cross-gendered behavior, but in their persistence. It is the disordered and chaotic family, according to Zucker, that can’t get its act together to present a consistent and sensible reaction to the child, which would be something like the following: “We love you, but you are a boy, not a girl. Wishing to be a girl will only make you unhappy in the long run, and pretending to be a girl will only make your life around others harder.” So the first prong of Zucker’s approach is family therapy. Whatever conflicts or issues that parents have that prevent them from uniting to help their child must be addressed.

Zucker is open about his belief that transness should be avoided if at all possible:

Despite these difficulties, Zucker clearly feels it’s important to at least attempt change. He points out that the burden of living as the opposite gender is great, and should not be casually embraced.

“We’re not talking about minor medical treatments. … You’re talking about lifelong hormonal treatment; you’re talking about serious and substantive surgery,” he says.

Failure to intervene increases the chances of transsexualism in adulthood, which Zucker considers a bad outcome. For one, sex change surgery is major and permanent, and can have serious side effects. Why put boys at risk for this when they can become gay men happy to be men?

(In fairness to Zucker, he is noted as “the first to acknowledge that no scientific studies currently support the effectiveness of what he does.”)

Alice Dreger, a bioethicist who previously compared gender-questioning kids to children who unseriously pretend to be train engines, promotes a similar idea. She’s cited unnamed clinicians as agreeing that these children are the product of “dysfunctional” families:

Here’s more unwelcome news from Ms. Dreger. A child’s gender issue may merely be a symptom of other family problems. “The dirty little secret is that many of these families have big dysfunctional issues. When you get the clinicians over a beer, they’ll tell you the truth. A lot of the parents aren’t well in terms of their mental health. They think that once the child transitions, all their problems will magically go away, but that’s not really where the stress is located.” Clinicians won’t say these things publicly, she says, because they don’t want to sound as if they’re blaming gender problems on screwed-up families.

Dreger likewise depicts transitioning as undesirable, and endorses alternatives where possible:

Sex-changing interventions are nontrivial. They involve substantial physical risk, including major risk to sexual sensation, and a lifelong commitment to trying to manage hormone replacement. …

But somehow if we wrap these major interventions around gender identity, we’re supposed to believe they are not that big a deal in terms of planning for a child’s future? And the clinician who tries to get a gender dysphoric kid to learn to like her or his innate body really is a Nazi? Not buying it. …

What if a boy could go to school in a dress and still be a boy? What if a girl could declare she’s going to grow up to be a man without being dragged to a clinic for a cure and/or prep?

As a trans woman, my diagnosis of depression exists within the context of these widespread attitudes. We live in a society where transitioning is regarded as a “bad outcome”, a last resort, only to be pursued when all other avenues for dealing with this discomfort have been exhausted. Are you sure you’re not just gay? Maybe you only think you’re trans because you’re afraid of other men. Can’t you wear a dress and still be a boy?

We’re warned that this may be no more than an illusory “fantasy solution” to our real problems. Commonplace medical practices reflect this overabundance of caution, something which became all the more striking when compared to my recent experiences. Unlike in 2012, I did not need to find one of the few therapists in a city of millions who would evaluate me and provide a lengthy referral letter for treatment. Instead, I was able to go to the same doctor as the rest of my family, and soon found myself sitting in an exam room full of detailed posters about depression and the drugs that might help. Within 30 minutes, I walked out with a prescription in hand. Trans people are often asked to consider whether they may just be depressed cis people – but depressed cis people are rarely asked to consider whether they might be trans.

Yet I’ve now found out that my ongoing unhappiness has persisted through transition, and so I’ve opted to receive treatment for depression. What am I supposed to make of that? And what will others make of it?

 

8. Relationships between dysphoria and depression

Actually, there are some critical (and obvious) flaws in the notion that other mental health conditions may serve as an “alternative explanation” to apparent gender dysphoria.

For one, there is no reason why gender dysphoria and other mental illnesses should be seen as mutually exclusive. If you’re trans, having depression doesn’t suddenly make you no longer trans. (For that matter, neither does childhood bullying, sexual abuse, autism, and so on.) Would anyone ever make a similar argument about physical conditions – that, say, you can’t have both Crohn’s disease and migraine headaches? Those also make me feel pretty terrible, but it would be absurd to claim that only one of these is responsible for the entirety of my physical pain. There is no reason they can’t coexist as contributors to that pain. And just as I’ve had to acknowledge that my gender dysphoria alone isn’t sufficient to explain all of my mood issues, it would be equally faulty for someone else to claim that my depression alone would suffice to explain this.

Does it seem at all realistic that there would be no occurrence of depression among trans people? People sometimes get depressed, and trans people are people. Scientific studies confirm, rather predictably, that gender dysphoria and depression can coexist. A 1997 study of 435 trans people found that they experienced psychiatric conditions at a rate similar to cis people:

Specifically, gender dysphoric individuals appear to be relatively “normal” in terms of an absence of diagnosable, comorbid psychiatric problems. In fact, the incidence of reported psychiatric problems is similar to that seen in the general population. Similarities in incidence included depression, bipolar disorder, and schizophrenia. … Although a small percentage of gender dysphoric individuals in this sample had prior identifiable psychiatric problems (7-10%), this is not inconsistent with the general population.

And a 2010 study found comparable levels of mental health conditions in 579 people diagnosed with gender dysphoria:

Adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579).

Furthermore, studies of trans people undergoing medical transition have consistently confirmed that these procedures are significantly helpful in addressing the symptoms of other mental health conditions, and increase our general well-being. Hormone therapy, in particular, stands out as a key factor in reducing levels of distress. A 2013 study followed 57 trans people before and after HRT and genital reassignment surgery, and found that starting HRT was associated with a marked decrease in depression and anxiety:

A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated.

Another study of 70 trans people examined their self-reported stress and their blood levels of cortisol, a hormone associated with stress. Being on HRT was linked to a reduction in perceived stress levels and cortisol awakening response:

At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples.

And in another study of 187 trans people, initiation of hormone therapy was associated with reduced symptoms of depression and anxiety:

Overall, 61% of the group of patients without treatment and 33% of the group with hormonal treatment experienced possible symptoms (score 8–10) or symptoms (score >11) of anxiety. The same pattern was found for symptoms of depression; the percentages were significantly higher in the group of patients without treatment (31%) than in the group on hormonal treatment (8%).

A study tracking 118 trans people before and after hormone therapy found that their levels of depression, anxiety, and functional impairment were much lower after HRT:

Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment).

And a study of 67 trans people found that those who received HRT had a higher quality of life, reduced depressive symptoms, and better self-esteem:

After adjusting for age, gender identity, educational level, partnership status, children at home, and sexual orientation, hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and higher psychological-like dimensions of QoL (psychological well-being and taking care of oneself of the SQUALA).

These studies suggest that the relief of depressive and anxious symptoms I experienced upon starting HRT was not something I only imagined – it is a phenomenon that has been repeatedly observed among many other trans people. Conversely, those trans people who did not receive HRT were noted to have higher levels of these depressive and anxious symptoms. This doesn’t bode well for the notion that trans people should first seek relief from their distress through means other than transitioning; medical transition may be exactly what they need.

This is not a mere “fantasy solution” as described by a handful of bombastic personalities who traffic in media controversy. This is real: for trans people, transitioning works. That doesn’t mean it’s a miracle cure-all – and really, what is? – but it does mean that it helps.

 

9. How transitioning helped me

For trans people who are depressed, treatment for depression is not a substitute for transitioning – it is an additional treatment for an additional condition. Being treated for depression hasn’t made me feel that my transition is any less necessary, or that my womanhood is any less important; I continue to be far more comfortable than I ever was as a “guy”. If anything, I know that the experience of transitioning has put me in a far better position to handle a challenge like depression.

Before I made the decision to start HRT, I saw it as something to put off for as long as possible: it was a last resort, to be used only in the event that any further physical masculinization became intolerable. Eventually, I took a more proactive stance, realizing that it would be better to avert those changes as early as possible. And when I finally started transitioning, I was astonished that I had been missing out on the mental benefits of HRT for so long.

What I learned was: don’t wait. I didn’t have to spend all that time enduring daily discomfort when there was a treatment right in front of me that could have helped. And I wasn’t going to make that mistake again. As soon as I recognized that I was likely experiencing depression, I made an appointment – there was simply no good reason to put it off. The sooner I received treatment, the sooner I could start getting better.

Transitioning taught me what it was like to feel truly good for the first time in my whole life. And this contrast showed me that what came before, the fog of constant unease and dissatisfaction and emotional numbness, was not normal. If I hadn’t transitioned, I might never have learned that there was an alternative – that I didn’t have to feel that way. I wouldn’t have known that this perpetual struggle to cope with my own existence meant that something was wrong.

So when my depression set in, I realized that my search for answers shouldn’t stop at “I guess that’s just how it is”. I knew I had to do something to fix this. As I described it to my doctor: “it feels like before I transitioned.” I have that frame of reference now, with an intimate understanding of just how awful and terrifying that feeling is.

Transitioning, quite simply, improved me. It made me into a more confident, capable, perceptive, outgoing, and overall emotionally well-rounded person. And it made me realize that I matter. At last, I love the person I am, the face I see in the mirror, the mind that can finally work at its full strength. Transition made me care about myself, and now I know that I deserve the best in life. I don’t deserve to suffer.

 

10. The story so far

Like HRT, I had no idea how this would feel before I started, and I wasn’t sure if it would even make a noticeable difference. But, also like HRT, I’ve now found that it makes a very noticeable difference. By the end of the day, the stress usually hasn’t overwhelmed me, and it fades more quickly rather than sticking around indefinitely. I’m getting more things done, and I’ve even started to write again. I’m just plain happy – or, at least, content.

Before, I’d been struggling to stay above water; now, it’s like sitting in a glass-bottom boat. I can still see and contemplate all the things that had dragged me down before – the sense that I’m worthless, the apparent pointlessness of existence, the question of why I keep going, the knowledge that my body is still wrong – but the dark things are behind a barrier now, and they’ve mostly lost their power to lash out and sink their teeth into me. I could choose to think about them, but I usually don’t; my mind isn’t drawn to them because there’s very little appeal there. Those thoughts rarely arrive uninvited, and they don’t stay for long.

Heather says that my mood is more like that of when I first transitioned. And it does feel like that. I once described HRT as like running my consciousness through a noise removal filter, and my antidepressants seem to have a similar effect. It makes me confident that I’ve made the right decision. It isn’t perfect – I’ve also had a moderate increase in panic attacks, and I’m now being treated for that as well. But, altogether, things are improving. My doctor agrees, and says I can stay on it for as long as I feel it’s helpful. He’ll see me again in three months.

I realize that these are still the early days and anything I say about depression and its treatment still comes from a place of inexperience. There’s certain to be surprises ahead, just as my first excited videos about HRT only offered a snapshot in time that couldn’t predict all the changes that would follow. It could get worse, like dysphoria can get worse. My current medications could eventually stop working, like hormones did. As always, things are going to keep changing, and I won’t know how until it happens.

I still worry that this pattern will keep repeating – that my entire life will just be a constant sprint from one apparent solution to the next, without ever being able to settle on any final answer. But hormones bought me a good year, and hopefully this will too. Transitioning meant checking one thing off the list. Treating my depression is checking off another thing. However long that list may turn out to be, I’m chipping away at it. ■

---