Transphobia-Based Violence,Depression,and Anxiety in Transgender Women: The Role of Body Satisfaction

Abstract

Psychological processes may mediate the relationship between minority stress and mental health though limited data exist showing this pathway among trans women. Trans women’s degree of satisfaction with their body is associated with mental health outcomes. This study used a model of minority stress to explore for indirect effects on the association between transphobia-based victimization and anxiety and depression through one’s degree of body satisfaction. Analysis also explored for racial differences. Transgender women (N = 233) were recruited in 2013 using respondent-driven sampling. Sociodemographics, transphobia-based victimization experiences such as having been physically abused, body satisfaction, and mental health were measured. Analyses assessed for direct and indirect associations while controlling for gender confirmation therapies (i.e., cross-sex hormone therapy and gender confirmation surgeries) and racial identity; 57% reported depression and 42.1% reported anxiety diagnoses. Participants averaged nearly three of six assessed violence experiences. More than 20% reported low body satisfaction. Contrary to authors’ expectations, those reporting African American and Other racial identity experienced less transphobia-based violence than whites. Transphobia-based violence was significantly associated with anxiety, depression, and body satisfaction. Body satisfaction was associated with mental health diagnoses. Bootstrapping revealed significant indirect and total effects. Body satisfaction mediated the relationship between transphobia-based violence and mental health. Clinical intervention that promotes body satisfaction including access to gender confirmation therapies, especially hormone therapy, may prevent negative mental health outcomes among trans women. Individual intervention, however, is not a panacea for structural discrimination. Attention to structural interventions that reduce gender minority stressors including transphobia-based violence is necessary.

Keywords

transgender stigma violence minority stress mental health

Transgender women, or trans women, are individuals who were assigned male sex at birth with the expectation they would have concordant gender identities (e.g., man) and masculine gender expression, yet have gender identities such as transgender woman or woman, and feminine gender expression (Hoffman, 2014). Often, trans women take steps to achieve a feminine gender presentation to be affirmed in their gender identity, that is to be socially recognized as women. Steps taken may include use of gender confirmation therapies such as cross-sex hormones and gender confirmation surgeries (e.g., facial feminization surgery or orchiectomy). Trans women’s satisfaction with the way their body looks is an important internal psychological evaluation that is a component of one’s gender identity affirmation and an important factor in the overall health of trans women (Kozee, Tylka, & Bauerband, 2012; Sevelius, 2013). For example, trans women who have accessed gender confirmation therapies and are satisfied with the way their bodies look experience significantly reduced self-injurious behavior and improved mental health (Burnes, Dexter, Richmond, Singh, & Cherrington, 2016; Singh & McKleroy, 2011).

It is important to note that not all transgender individuals cognitively conceptualize and behaviorally present dimensions of gender within a binary framework (The GenIUSS Group, 2014; Hendricks & Testa, 2012). A binary conceptualization of sex and gender suggests that one is biologically sexed either female or male, with either feminine or masculine gender identity and expression. However, many individuals’ gender identity and expression do not align with the social expectations placed on their sex assigned at birth and do not identify as either trans men or trans women, but instead as genderqueer, two-spirit, or gender nonbinary to give but only three examples of a multiplicity of gender identities (Hendricks & Testa, 2012). Research on the experiences of the large swatch of society that is nonconforming to gender norms is needed (Institute of Medicine, 2011; Reisner, Deutsch, et al., 2016; Reisner, Poteat, et al., 2016). The present study looks at the experiences of a sample of trans women. Trans women experience disproportionately high experiences of violence and behavioral health outcomes compared with white cisgender individuals in the United States, likely as a result of interpersonal and intrapersonal gender minority stress with origins in the structural environment (Dinno, 2017; Hatzenbuehler, 2014; Hatzenbuehler, Corbin, & Fromme, 2008; Serano, 2016; Stotzer, 2017; Testa, Habarth, Peta, Balsam, & Bockting, 2015; Xavier, Bobbin, Singer, & Budd, 2005). Cisgender individuals are those whose sex assigned at birth is in concordance with the social expectations of gender identity and presentation placed upon them given their assigned sex at birth (The GenIUSS Group, 2014).

Violence at the Intersection of Transphobia and Racism

While unidimensional analytic frames take gender or race into account separately, an intersectional approach allows researchers to consider trans women’s lived experience at the margins of multiple identities (Crenshaw, 1991; Singh & McKleroy, 2011). That trans women take steps to present as their authentic gender, which is in opposition to the social expectations placed upon them given their sex assigned at birth; they can be considered to defy the existing gender order (Connell & Pearse, 2015; Serano, 2016). Defiance of hegemonic gender norms by these individuals subjects them to structural and interpersonal violence due to misogyny and transphobia, or transmisogyny (Serano, 2016). Examples include laws and policies that deny transgender individuals affirmation of their identity, such as a requirement at homeless shelters for individuals to present as their sex assigned at birth rather than as their authentic gender (Begun & Kattari, 2016) and, at the interpersonal level, as brutal physical violence that enforces hegemonic gender roles (Connell & Pearse, 2015; Serano, 2016). In the present study, these experiences of violence are termed transphobia-based violence.

In addition to transphobia-based violence, trans women of color also encounter racism given their position as racial and ethnic minorities in the United States (Sevelius, 2013; Singh & McKleroy, 2011; Stotzer, 2017; Xavier et al., 2005). Social location at the intersection of racial minority status and transgender experience place trans women at increased exposure to structural and interpersonal discrimination. The racist experiences encountered by these multiply marginalized individuals are termed microaggressions, which are explicit racist assaults, as well as insults and invalidation that may seem innocuous to perpetrators yet place people of color at a heightened state of fear and hopelessness (Balsam, Molina, Beadnell, Simoni, & Walters, 2011). Racial microaggressions, in tandem with the stress associated with transphobia, are hypothesized to have an additive effect on the health outcomes of racial minority transgender people (Balsam et al., 2011; I. H. Meyer, 2010). Examination and documentation of the effect of racial and ethnic minority group identification and trans women experience on violence and mental health outcomes require further study (Balsam et al., 2011; Dinno, 2017; Stotzer, 2017).

Violence and Mental Health Disparities

Existing empirical research on trans women has shown that violence starts early in their lives and lasts throughout their lifetime, and that they are at risk of multiple types of violence (Grant et al., 2011; Stotzer, 2009). Studies have reported that nearly 40% of trans women experience physical victimization (Testa et al., 2012), 25% encounter discrimination at least once or twice a week, and 51% have been physically assaulted at least a couple times a month to daily (Bazargan & Galvan, 2012). Trans women also experience economic and housing discrimination, and homelessness at about twice the rate of the general population, and economic disenfranchisement such as homelessness is associated with increased likelihood of encountering physical violence (Begun & Kattari, 2016). It comes as no surprise that experiences of transphobia-based violence relate to mental health outcomes.

Mental health disparities exist among trans women compared with the U.S. general population (Bazargan & Galvan, 2012; Budge, Adelson, & Howard, 2013; Gamarel, Reisner, Laurenceau, Nemoto, & Operario, 2014; Hoffman, 2014), and studies show that transphobia-based violence is related to increased depression and anxiety (Budge, Adelson, et al., 2013; Hoffman, 2014; Jauk, 2013; Levitt & Ippolito, 2013; Nuttbrock et al., 2014a, 2014b; Testa et al., 2017). Lifetime prevalence of depression has been reported as high as 63% among transgender samples compared with a prevalence of 16.6% generally (Hoffman, 2014; Reisner, Poteat, et al., 2016). Furthermore, rates of suicidality among transgender individuals are high, which may be explained by the persistent threat of violence present in their lives (Testa et al., 2017). In one study of transgender adults, participants reporting experience of transphobia-based violence in their youth were found to have a fourfold increase in likelihood to attempt suicide over those transgender individuals who did not experience such violence (Goldblum et al., 2012). Public health professionals have been encouraged to focus on the mental health of trans women for over a decade, yet reviews of literature continue to show neglect and a need for further researcher (Bazargan & Galvan, 2012; Reisner, Poteat, et al., 2016).

Minority Stress

A model that considers minority stressors experienced by transgender people has been used to explain the prevalence of depression and anxiety in this population (Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013; Gamarel et al., 2014; Hendricks & Testa, 2012; Testa et al., 2015). This theoretical model stemming from minority stress theory (I. H. Meyer, 2003) posits that because transgender people are disenfranchised socially and economically, they are exposed to heightened and persistent stress in the social environment (e.g., transphobia-based violence; Gamarel et al., 2014). This distal stress leads to negative psychological self-evaluations, which are considered proximal minority stressors. Over time, the ability to cope and be resilient in the face of these internalized stressors weakens, resulting in the observed prevalence of negative mental health outcomes in trans women (Testa et al., 2015; Testa et al., 2012).

Complete understanding of trans women’s minority stress processes has not been achieved and further research is needed (Testa et al., 2017). This study examined the role of body satisfaction in the relationship between violence, and anxiety and depression in a sample of trans women from a large metropolitan area. Body satisfaction, an internal psychological process that is a component of one’s gender identity affirmation, is an important factor in the overall health of trans women (Kozee et al., 2012; Sevelius, 2013). For example, body satisfaction has been found to correlate with lower levels of depression and anxiety (Glynn et al., 2016; Kozee et al., 2012). The minority stress framework suggests that psychological self-appraisal such as one’s degree of body satisfaction may mediate the relationship between structural stressors like violence and mental health outcomes (see Figure 1), although further evidence is needed (Hatzenbuehler, 2009; Hendricks & Testa, 2012; Testa et al., 2015). Studies have shown discrimination and violence to be significant associates of depression and anxiety among trans women (Bazargan & Galvan, 2012; Bockting et al., 2013; Gamarel et al., 2014). Body satisfaction, however, may mitigate the negative effects of transphobia-based violence and discrimination on depression and anxiety (Begun & Kattari, 2016; Gamarel et al., 2014; Glynn et al., 2016; Kozee et al., 2012). To our knowledge, there are currently no studies that look at the mediating role of body satisfaction on the relationship between transphobia-based violence and mental health outcomes, and our study hopes to address this gap in literature. Our hypotheses are as follows:

Hypothesis 1: That trans women of color will experience significantly more transphobia-based violence than white trans women.

Hypothesis 2: That one’s degree of body satisfaction will mediate the relationship between experiences of transphobia-based violence, and depression and anxiety diagnoses in trans women controlling for racial identity and lifetime access to gender confirmation therapies.

Figure 1.

Minority stress conceptual model: Proximal stress as mediator of relationship between transphobia-based violence and mental health outcomes.

Empirical support for intervention targets is sorely needed for trans women (Glynn et al., 2016; Hendricks & Testa, 2012; White Hughto, Reisner, & Pachankis, 2015). Indirect effects of body satisfaction on the relationship between violence and mental health outcomes would reveal important intervention targets and direct future research.

Method

Following a respondent-driven sampling (RDS), a method used to obtain robust and diverse samples of hard-to-reach populations (Heckathorn & Cameron, 2017), the study began with key informant interviews of trans women in San Francisco, California, in 2013. The key informants were contacted for interview with the assistance of community and program partners of the San Francisco Department of Public Health (SFDPH). These interviews led to the purposeful selection of 12 starting participants diverse in terms of age, race, and education who were contacted through our extensive health and community service network. Each starting seed (a term used in RDS to describe the first study participants) was asked to recruit three individuals, who in turn were asked to recruit three additional individuals each. This iterative sampling process continued until stability was achieved, a state at which the composition of the sample as measured by the proportions of key variables including race and age stops changing (Obedin-Maliver et al., 2011). The study had long recruitment chains (mean recruitment wave = 3.4; range = 0-9) and moderate homophily with respect to race and ethnicity (range = 0.05-0.47). Each participant received three to five recruitment cards to use in their recruitment of potential study participants. The coupon return rate was 33.1%; 233 trans women were recruited over a 5-month period from August to December.

Eligibility criteria for the study included self-report as a transgender woman, being at least 18 years of age, and current residence in the city of San Francisco. Among the 250 trans women who were screened for eligibility, 93.6% were deemed eligible and agreed to participate. All study procedures took place in confidential research offices at the SFDPH. After providing informed consent, each respondent completed a standardized survey administered face-to-face by a study staff member via a computer-assisted personalized interview on a tablet computer that took no more than 60 min. Research staff were trained to administer the survey by verbally reading each question and answer choice aloud, and when needed, to provide participants with alternative wording and more information to ensure participant understanding. Training of study staff was overseen by the study coordinator and principal investigator (PI) who observed staff interviewing and provided feedback. One health outcome of interest to the primary study was HIV status, and upon completion of the survey, participants also completed an HIV rapid test. All study procedures received approval from the Committee on Human Research at the University of California, San Francisco, and all participants provided verbal informed consent. Participants received US$50 for participation and US$10 for each successful recruit up to five people each. The current study is a secondary analysis by the lead author. The second and third authors were the study coordinator and PI, respectively, of the primary study examining HIV incidence and prevalence among trans women in San Francisco.

Measures

The survey was created in collaboration with the Transgender Advisory Group (TAG), an open standing committee at SFDPH. The TAG consists of community members, advocates, and transgender health service providers who serve in an advisory capacity to inform SFDPH projects and activities. TAG membership is voluntary, and members are not compensated. Sociodemographic characteristics such as gender identity, race and ethnicity, whether the participant was born in the United States or not, monthly income, level of education, and housing status were measured. Variables included in the current analysis are the following items, all original excluding our questions for racial and ethnic identity. Racial and Ethnic Identity: Respondents were first asked if they were Hispanic or Latina and then, “Which racial group do you consider yourself to be in?” Respondents could select as many options as needed. The responses were coded into the following categories, “Asian, African American, Native American/Alaskan Native, Native Hawaiian or other Pacific Islander, white, Latina, Mixed, and Other.” For analysis, any individual selecting more than one racial group was placed into the mixed category, and Asian, and Native Hawaiian or other Pacific Islander were consolidated with Other due to a low response rate for each category. Hormone Use: Lifetime hormone use was assessed in a single binary item asking, “Have you ever taken hormones or other drugs to enhance your gender presentation?” Gender Confirmation Surgery: One binary item asked, “Have you ever had any gender confirmation surgery?” Those responding yes were asked a follow-up question, “What types of gender confirmation surgery have you had? (check all that apply).” Possible response included penectomy (removal of the penis), bilateral orchiectomy (removal of the testicles), vaginoplasty, breast enhancement, and facial feminization surgery.

Transphobia-based victimization

Violence experiences were assessed using six individual binary response questions asking about lifetime experiences of the following based on gender identity or presentation: being fired from a job, having trouble getting a job, being denied or evicted from housing, having trouble getting health or medical services, experiencing verbal abuse or harassment, and experiencing physical abuse or harassment. Question examples include the following: “Have you ever been fired from a job because of your gender identity or presentation?” and “Have you ever been verbally abused or harassed because of your gender identity or presentation?” Responses were summed into a single variable for the total number of transphobia-based violence experienced (range = 0-6). Body Satisfaction: Four questions assessed respondents’ level of satisfaction with their body: “How satisfied are you with the way your body looks today?”; “How satisfied are you with your upper body?”; “How satisfied are you with your lower body?”; and “How satisfied are you with your weight?” Responses were on a 4-point Likert-type scale from 1 (mostly satisfied) to 4 (mostly dissatisfied). The four responses were averaged to represent overall body satisfaction. For analysis, the variable’s valence direction was changed so that values ranged from 1 (mostly dissatisfied) to 4 (mostly satisfied). Mental Health Outcomes: Lifetime diagnoses of anxiety and of depression were assessed in a single self-reported item. The item began, “There are different types of mental health issues people deal with. Have you been diagnosed with any of the following mental health issues? (check all that apply).” Anxiety and depression were two of seven selectable options. One option was, “never been diagnosed with mental health issues.” Two dichotomized variables were created from this single self-report item, one each for depression and anxiety.

Analysis

To begin, authors conducted descriptive analysis of study variables. Next, ordinary least squares (OLS) regression analysis was used to explore for significant difference by racial identity. Subsequently, body satisfaction was examined for potential significant indirect effect on the relationship between transphobia-based victimization and depression and anxiety in two separate models (see Figure 1 for mediational path conceptualization). First, transphobia-based violence was included in a model as an associate of body satisfaction (path a). Next, separate models were run excluding body satisfaction and exploring transphobia-based victimization as an associate of mental health diagnoses (path c). To assess indirect effects (paths b and c′), separate models were run with body satisfaction and transphobia-based victimization as associates of anxiety and depression diagnoses. Finally, to obtain standardized coefficients for the indirect, direct, and total effects of the analyses, bootstrapping procedures using 5,000 replications for each mediation model were conducted. Racial identity, lifetime hormone use, and ever having had a gender confirmation surgery were included as covariates in all mediation analyses. The alpha level was set at .05 for all tests. Checks for model assumptions were completed, including checks for multicollinearity. Analysis was conducted in Stata Version 14.

Results

Sociodemographic Characteristics

Descriptive statistics are summarized in Table 1. More than half of the sample was aged 46 or older (56.0%). Racial background of the sample was diverse, with the largest group being Latina (33.1%). Four fifths (80.3%) of the sample reported making less than US$1,251 in monthly income. About 30% of the sample had less than a high school education. A similar proportion reported high school education. Less than 10% graduated college or had education beyond college. Over three quarters of respondents had taken hormones in their lifetime or were currently taking hormones, while a much smaller proportion of the sample reported having had any gender confirmation surgery (27.5%).

Table 1.

Sample Characteristics of Trans Women in San Francisco, California, 2013 (N = 233).

Characteristics	n	%
Age
18-20	5	2.2
21-25	12	5.2
26-30	13	5.6
31-35	13	5.6
36-40	29	12.5
41-45	30	12.9
46-50	57	24.5
>50	74	31.8
Race and ethnicity
white	43	18.5
African American	65	27.9
Latina	77	33.1
Mixed	31	13.3
Asian	5	2.2
Native American/Alaskan Native	3	1.3
Native Hawaiian or Other Pacific Islander	5	2.2
Other	4	7.3
Monthly income (US$)
0-417	31	13.3
418-833	48	20.6
834-1,250	108	46.4
1,251-1,667	12	5.2
1,668+	33	14.2
Education
Less than high school	67	28.8
High school	71	30.5
Some college	72	30.9
College graduate/graduate	23	9.8
Born in the United States
Yes	182	78.1
No	51	21.9
Homeless
Yes	34	14.6
No	189	85.4
Ever taken hormones to enhance gender presentation?
Yes	208	89.3
No	25	10.7
Currently taking hormones to enhance gender presentation?
Yes	159	76.4
No	49	23.6
Ever had any gender confirmation surgery?
Yes	64	27.5
No	169	72.5
Received a penectomy
Yes	11	4.7
No	222	95.3
Received a bilateral orchiectomy
Yes	21	9.0
No	212	91.0
Received vaginoplasty
Yes	23	9.9
No	210	90.1
Received breast enhancement
Yes	40	17.2
No	193	82.8
Received facial feminization surgery
Yes	16	6.9
No	217	93.1
HIV test result
Negative	149	64.0
Positive	84	36.0

Transphobia-based violence experiences, along with body satisfaction and mental health outcomes, are summarized in Table 2. Transphobia-based violence was common in the sample, as was self-report of anxiety and depression diagnoses. Slightly more than 25% of the sample reported being fired from a job because of their gender identity or presentation, whereas nearly half of the sample (47.2%) reported trouble getting a job for the same reason. More than one quarter of participants reported being evicted or denied housing (27.7%), as well as problems getting health or medical services (25.4%). In this sample, 84.1% reported verbal and 63.5% reported physical abuse or harassment. Less than 10% reported no transphobia-based violence, 19.4% reported one experience, 22.5% reported two, nearly 41% reported between three and five, and 7.9% reported all six experiences of violence. The mean number of transphobia-based violence experiences reported was 2.7 (SD = 1.8). About 77% of the sample reported satisfaction with the current appearance of their body, 73.3% with their upper body, and 64.5% with their lower body. A similar proportion was satisfied with current weight (61.9%). The mean body satisfaction score was 2.87 (SD = 0.80). Regarding mental health, 57.5% reported being diagnosed with depression and 42.1% reported being diagnosed with anxiety. Tests indicated no concern for multicollinearity.

Table 2.

Transphobia-Based Violence, Degree of Body Satisfaction, and Mental Health Outcomes of Trans Women in San Francisco, California, 2013 (N = 233).

Characteristics	n	%
Fired from job based on gender identity or presentation
No	171	74.0
Yes	60	26.0
Trouble getting a job based on gender identity or presentation
No	122	52.8
Yes	109	47.2
Denied housing or evicted based on gender identity or presentation
No	167	72.3
Yes	64	27.7
Problems getting health or medical services based on gender identity or presentation
No	173	74.6
Yes	59	25.4
Verbally abused or harassed based on gender identity or presentation
No	37	15.9
Yes	196	84.1
Physically abused or harassed based on gender identity or presentation
No	85	36.5
Yes	148	63.5
Number of victimization experiences
0	21	9.3
1	44	19.4
2	51	22.5
3	36	15.9
4	31	13.7
5	26	11.5
6	18	7.9
Satisfaction with current appearance of body
Mostly satisfied	96	42.5
Somewhat satisfied	80	35.4
Somewhat dissatisfied	33	14.6
Mostly dissatisfied	17	7.5
Satisfaction with current appearance of upper body
Mostly satisfied	99	44.0
Somewhat satisfied	66	29.3
Somewhat dissatisfied	31	13.8
Mostly dissatisfied	29	12.9
Satisfaction with current appearance of lower body
Mostly satisfied	80	35.6
Somewhat satisfied	65	28.9
Somewhat dissatisfied	28	12.4
Mostly dissatisfied	52	23.1
Satisfaction with current weight
Mostly satisfied	74	32.7
Somewhat satisfied	66	29.2
Somewhat dissatisfied	40	17.7
Mostly dissatisfied	46	20.4
Depression
No	99	42.5
Yes	134	57.5
Anxiety
No	135	57.9
Yes	98	42.1

Bivariate Results

OLS regression results revealed that African Americans and those in the Other racial category experienced significantly less transphobia-based violence than whites (Table 3). Regression indicated that racial and ethnic identity explained 4.5% of the variance in transphobia-based violence, F(4, 222) = 2.67, p = .033. African Americans (b = –0.933, p = .008) and those in the Other racial identity category (b = –1.274, p = .012) had significantly fewer experiences of transphobia-based violence than white trans women in our sample.

Table 3.

Standardized Regression Coefficients, Racial and Ethnic Identity’s Association on Number of Transphobia-Based Violence Experiences (Range = 0-6).

Racial and ethnic identity	b	SE	β, p-value
Black/African American	–.933	.349	–.241, p = .008
Latina	–.653	.341	–.175, p = .057
Mixed race	–.301	.415	–.059, p = .470
Other	–1.274	.502	–.191, p = .012

Note. Reference group is white reported racial identity.

Mediation Analysis Results

Transphobia-based violence was significantly associated with reports of depression and anxiety controlling for racial identity, lifetime hormone use, and gender confirmation surgeries. For each additional violence experience, the odds of reporting a depression diagnosis increased 1.2 times (b = 0.204, p = .015) and the odds of an anxiety diagnosis also increased by 1.2 times (b = 0.188, p = .02). Transphobia-based violence was also significantly associated with the degree of body satisfaction (b = –0.134, t = –4.88, p < .001). Compared with white individuals in our sample, African Americans had significantly higher body satisfaction (b = 0.534, t = 3.54, p < .001). Also, lifetime hormone use was significantly related to a higher degree of body satisfaction (b = 0.368, t = 3.29, p = .001). Body satisfaction was significantly associated with reports of depression diagnosis (b = –0.495, p = .021, odds ratio [OR] = 0.61) and anxiety diagnosis (b = –0.809, p < .001, OR = 0.44). Racial identity and gender confirmation therapies including hormone use had no significant relationship with depression and anxiety. In analysis assessing for significant association between transphobia-based violence and anxiety diagnosis (path c), report of hormone use was related to 4 times higher odds of anxiety (b = 1.550, p = .01, OR = 4.71).

Subsequent analyses examined the relationship of transphobia-based violence on mental health outcomes in the presence of body satisfaction while controlling for racial and ethnic identity and gender confirmation therapies. Formal mediation models were used to summarize the strength of direct and indirect pathways to anxiety and depression diagnoses from transphobia-based violence through body satisfaction. In the presence of body satisfaction, the effect of transphobia-based victimization on reports of depression and anxiety decreased substantially. In these subsequent analyses, the direct effect of transphobia-based victimization on anxiety and depression was not statistically significant. However, significant indirect effects existed from transphobia-based violence to depression and anxiety through degree of body satisfaction. The significant effect of African American identity on anxiety diagnosis fell from significance in the full model while the effect of lifetime hormone use on anxiety diagnosis remained (b = 1.572, p = .01, OR = 4.80). The total effects of transphobia-based violence and body satisfaction on reports of anxiety and depression diagnoses were also significant. In our models, 31.7% of the total effect of transphobia-based violence on depression was mediated by body satisfaction, whereas 53.3% of the total effect of transphobia-based violence on anxiety was mediated by body satisfaction. Hosmer and Lemeshow’s goodness-of-fit test was conducted on all models and suggested good fit. The results of the bootstrapping procedure for mediation analysis are summarized in Table 4.

Table 4.

Mediational Analyses of Body Satisfaction on Relationship Between Multiple Victimization and Depression and Anxiety Adjusting for Racial Identity and Gender Confirmation Therapies Among Trans Women in San Francisco, California, 2013 (N = 233).

	b	SE	95% CI
Depression
Indirect effect	.061	.029	[.012, .127]
Direct effect	.132	.081	[–.041, .279]
Total effect	.194	.073	[.023, .335]
Anxiety
Indirect effect	.098	.033	[.041, .171]
Direct effect	.085	.085	[–.092, .244]
Total effect	.184	.081	[.006, .329]

Note. Statistical significance determined by 95% bias-corrected CIs based on 5,000 bootstrap samples. Significant effects in bold. CI = confidence interval.

Discussion

Calls have been made for the study of the effects of proximal minority stress on the relationship between structural stigma (distal minority stress) and negative mental health outcomes (Boza & Perry, 2014; Gamarel et al., 2014; Hatzenbuehler, 2009). In this study, body satisfaction had a significant mediating effect on the association between transphobia-based violence experiences and diagnoses of depression and anxiety. Increased victimization experiences were associated with lower degrees of body satisfaction. In addition, lower body satisfaction increased the likelihood of reporting diagnoses of anxiety and depression. Ultimately, more than a quarter of transphobia-based violence’s effect on depression diagnosis was mediated through body satisfaction, whereas nearly one half of its effect on anxiety diagnosis was mediated by body satisfaction.

Recent literature (Bockting et al., 2013; Gamarel et al., 2014; Hendricks & Testa, 2012) and the findings of this analysis further support application of the minority stress model (I. H. Meyer, 2003) in research with populations of trans women so as to better understand their experiences and to move preventionists toward the development of supportive evidence-based interventions. Gender appearance acceptance and gender identity affirmation are states of positive psychological self-appraisal that are predicated on one’s satisfaction with the way their body looks (Glynn et al., 2016; Kozee et al., 2012; Sevelius, 2013). Our findings highlight the important role of trans women’s body satisfaction on mental health outcomes. Social environmental stressors such as the transphobia-based violence experiences assessed in our study, which included verbal and physical violence, economic disenfranchisement, and discrimination in seeking health services and employment opportunities, were found to influence evaluations of self, as hypothesized in existing literature on transgender populations (Hendricks & Testa, 2012; Kozee et al., 2012). Scholars have suggested that internal psychological factors play an important role in mediating the relationship between environmental factors and the mental health outcomes of cisgender lesbian, gay, and bisexual people (Hatzenbuehler, 2009). Our findings support this hypothesis among trans women and suggest future research that further explores the mediating role of reliably measured psychological factors that may mediate distal minority stress experiences and negative mental health outcomes.

Although existing literature documents alarming rates of violence among trans women of color (Bazargan & Galvan, 2012; Grant et al., 2011; Serano, 2016), we found that African Americans and those in our variable for Other racial identity reported a lower rate of transphobia-based violence compared with whites. African American and transgender individuals have described their experiences of minority targeted violence as rooted in racial social dynamics and racism rather than in transphobia (D. Meyer, 2012). It is possible that participants of color therefore did experience higher rates of violence than whites, but felt that they experienced this violence primarily due to their racial identity and not because of their transgender experience. In addition, the extent to which racism in the United States is a pervasive part of daily life for people of color may result in the normalization and underreporting of these experiences. Also, empirical research has shown that being subjected to multiple minority stressors does not have an additive effect on negative outcomes (I. H. Meyer, 2010), likely due to resilience. Indeed, African American and Latina transgender individuals of color have been found to have unique resilience that assist them in navigating, coping with, and avoiding racial and transphobic violence in their communities and within their relationships (Singh, 2013). This in part may explain why Latinas did not differ from whites in our sample in regard to transphobia-based violence. Far from suggesting that there are no racial inequities among trans women, our results highlight a need for continued attention to racial inequity to clarify our findings.

Clinical and Policy Implications

At the individual level, these results highlight the importance of identifying for clinical intervention those trans women who have experienced multiple types of transphobia-based violence. For example, one study illustrated that trans women who are homeless or seeking services at homeless shelters are at increased risk of victimization (Begun & Kattari, 2016). Working with groups at risk of violence to promote their resilience in the face of these experiences is warranted. Given that low body satisfaction was related to diagnosis of depression and anxiety, clinical work that promotes body satisfaction may reduce the likelihood of these diagnoses. Lifetime hormone use was associated with increased self-affirmation, which has been shown elsewhere (Budge, Katz-Wise, et al., 2013; Singh & McKleroy, 2011). Thus, ensuring that gender confirmation therapies are accessible and affordable for those who desire them is indicated. That there was an association between hormones and anxiety among trans women in our sample is by no means a counterindication for use. Hormone use was also related to increased body satisfaction which we found to mitigate the impact of violence on mental health. Cognitive-behavioral therapy to promote body satisfaction is also indicated in our data, which has been suggested to promote body satisfaction and reduce depression with etiological roots in structural discrimination (Cassone, Lewis, & Crisp, 2016; Ross, Doctor, Dimito, Kueho, & Armstrong, 2007). However, cognitive-behavioral therapy is no magic solution for a social context of marginalization and violence that, if not changed, will continue to negatively affect appraisals of self and the mental health of trans women regardless of clinical interventions.

The promotion of a structural environment affirmative of transgender people has been highlighted as a promising avenue to increase positive self-evaluations, reduce interpersonal and intrapersonal stress, and decrease negative mental health outcomes (Hatzenbuehler, 2014). Paths toward the development of a supportive structural environment for transgender people include psychoeducation of communities on human gender diversity and the creation of policy and practices that not only seek to eliminate and protect against discrimination but also work toward the acceptance and affirmation of transgender people across contexts (Grant et al., 2011). Examples of needed changes include the use of gender-neutral language and markers on forms and identification documents in a variety of social care settings, and the gender affirmative training of health care and other social service staff members (Katz-Wise et al., 2017). Furthermore, protection of the right to housing and employment based on gender identity and expression, and refinement of hate crime and immigration policy that name gender identity as a protected status are also needed structural interventions (Grant et al., 2011). The removal of barriers to affirmative services such as a lack of insurance coverage or prohibiting copays for gender confirmation therapies are indicated by our data.

Limitations and Future Directions

That the original study’s aim was to document HIV prevalence is a limitation. Survey questions were created in partnership with a TAG, and overall brevity of the survey was stressed. Therefore, we did not use the most comprehensive measures available for distal and proximal minority stressors and mental health outcomes. For example, our self-report single-item question assessing for diagnoses of anxiety and depression may have excluded those in the sample who have diagnosable depression or anxiety but have not sought services. This is important given evidence that African American’s access of services is less than that of other racial groups in part due to expectations they will encounter racial microaggressions from counselors and that they have developed other resilience strategies to cope with stressors (Ayalon & Young, 2005; Balsam et al., 2011; Singh & McKleroy, 2011). Future research that more fully assesses components of the minority stress model using valid and reliable measures of transphobia-based violence, overall gender identity affirmation (our body satisfaction measure does not get at all dimensions of this construct), and mental health outcomes is warranted. Scales that assess the experiences of transgender individuals are lacking in evidence for reliability, validity, and sensitivity to change (Shulman et al., 2017). Overall, the lack of measures for structural-level gender minority stress and the variance in measures across studies limit the extent to which inferences can be made from the comparison of existing literature (Boza & Perry, 2014; Reisner, Poteat, et al., 2016). Nonetheless, there are promising scales in existence. For one, we recommend use of the Gender Minority Stress and Resilience Measure in nationwide surveys (Dinno, 2017; Stotzer, 2017; Testa et al., 2015). The Centers for Epidemiological Studies Depression Scale (CES-D) and the Hamilton Rating Scale for Anxiety (HAM-A) are measures of mental health that we also recommend (Stockings et al., 2015; Thompson, 2015).

Longitudinal studies are needed to determine causative relationships among outcomes, transphobia-based violence, and negative body satisfaction (Reisner, Poteat, et al., 2016). The gender minority stress model assumes causation of health outcomes due to preceding distal and proximal environmental stress, and our analysis followed this assumed causative pathway. Given our data are cross-sectional, we cannot prove causation. It is possible that diagnosis of depression may lead to negative body satisfaction. To establish causation, longitudinal studies that isolate experiences of violence and subsequent changes to behavioral health are needed. Future studies must also enroll diverse representative subgroup samples of gender nonconforming individuals.

Conclusion

Violence starts early and persists throughout transgender people’s lives. Recent literature shows no slowing of this trend, with especially negative impact on transgender people of color in comparison with the general U.S. cisgender population (Dinno, 2017). Transphobia-based violence has been correlated with depressive outcomes in multiple studies, including ours. The relationship between this violence and negative behavioral health outcomes must be addressed. We found that positive body satisfaction mitigates the likelihood of reporting a diagnosis of depression or anxiety among trans women. Service providers can use clinical interventions to increase positive body satisfaction among these women, although individual intervention is no panacea for a discriminatory structural environment. Service providers can focus on reducing violence and discriminatory practices and promoting the affirmation of transgender experiences in the social environment through policy and educational interventions that target employment, housing, health care services, and the law.

Footnotes

Acknowledgements

The authors would like to thank Michael Hurlburt, PhD, at the USC Suzanne Dworak-Peck School of Social Work, Univesity of Southern California.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the San Francisco Department of Public Health. The funder had no role in the conduct of the study or the preparation of this manuscript.

ORCID iD

Cary L. Klemmer

Author Biographies

Cary L. Klemmer is a social worker living in Los Angeles, California. He is currently a PhD student in social work. Using a feminist lens, and other behavioral health theories, he studies the associations of victimization, discrimination, gender identity, and gender expression on behavioral health outcomes such as anxiety, depression, and substance use. He hopes to promote a society supportive of lesbian, gay, bisexual, transgender and queer people with diverse gender expressions so that all can live well. He has experience as an HIV test counselor, and a clean syringes exchange service advocate.

Sean Arayasirikul roots lie in social justice, lesbian, gay, bisexual, and transgender (LGBT) activism, and HIV/AIDS prevention, care, and research. His personal experiences with homelessness, discrimination, and violence shape his practice of sociology. His diverse professional experiences range from providing HIV and other sexualy transmitted infection testing services on the streets of Los Angeles to providing mobile case management services to newly diagnosed, HIV-positive youth of color. Recently, he was a Health Policy Fellow at the Office of Disease Prevention and Health Promotion at the U.S. Department of Health and Human Services. He is a mixed-methods, mHealth, and social network scholar interested in LGBT health, gender, emotions, and identity.

Henry F. Raymond is the assistant director at the San Francisco Department of Public Health’s HIV Seroepidemiology Unit. He is an expert at the respondent-driven sampling methodology and guides both domestic and international projects in public health using that method.

References

Ayalon

Young

M. A.

(2005). Racial group differences in help-seeking behaviors. Journal of Social Psychology, 145, 391-404.

Balsam

K. F.

Molina

Beadnell

Simoni

Walters

(2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity & Ethnic Minority Psychology, 17, 163-174.

Bazargan

Galvan

(2012). Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health, 12, Article 663.

Begun

Kattari

S. K.

(2016). Conforming for survival: Associations between transgender visual conformity/passing and homelessness experiences. Journal of Gay & Lesbian Social Services, 28, 54-66.

Bockting

W. O.

Miner

M. H.

Swinburne Romine

R. E.

Hamilton

Coleman

(2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103, 943-951.

Boza

Perry

K. N.

(2014). Gender-related victimization, perceived social support, and predictors of depression among transgender Australians. International Journal of Transgenderism, 15, 35-52.

Budge

S. L.

Adelson

J. L.

Howard

K. A. S.

(2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81, 545-557.

Budge

S. L.

Katz-Wise

S. L.

Tebbe

E. N.

Howard

K. A. S.

Schneider

C. L.

Rodriguez

(2013). Transgender emotional and coping processes: Facilitative and avoidant coping throughout gender transitioning. The Counseling Psychologist, 41, 601-647.

Burnes

T. R.

Dexter

M. M.

Richmond

Singh

A. A.

Cherrington

(2016). The experiences of transgender survivors of trauma who undergo social and medical transition. Traumatology, 22(1), 75-84.

10.

Cassone

Lewis

Crisp

D. A.

(2016). Enhancing positive body image: An evaluation of a cognitive behavioral therapy intervention and an exploration of the role of body shame. Eating Disorders, 24, 469-474.

11.

Connell

Pearse

(2015). Gender in world perspective (3rd ed.). Cambridge, UK: Polity Press.

12.

Crenshaw

(1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43, 1241-1299.

13.

Dinno

(2017). Homicide rates of transgender individuals in the United States: 2010–2014. American Journal of Public Health, 107, 1441-1447.

14.

Gamarel

K. E.

Reisner

S. L.

Laurenceau

J.-P.

Nemoto

Operario

(2014). Gender minority stress, mental health, and relationship quality: A dyadic investigation of transgender women and their cisgender male partners. Journal of Family Psychotherapy, 28, 437-447.

15.

Glynn

T. R.

Gamarel

K. E.

Kahler

C. W.

Iwamoto

Operario

Nemoto

(2016). The role of gender affirmation in psychological well-being among transgender women. Psychology of Sexual Orientation & Gender Diversity, 3, 336-344.

16.

Goldblum

Testa

R. J.

Pflum

Hendricks

M. L.

Bradford

Bongar

(2012). The relationship between gender-based victimization and suicide attempts in transgender people. Professional Psychology: Research and Practice, 43, 468-475.

17.

Grant

J. M.

Mottet

L. A.

Tanis

Harrison

Herman

J. L.

Keisling

(2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality.

18.

Hatzenbuehler

M. L.

(2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135, 707-730.

19.

Hatzenbuehler

M. L.

(2014). Structural stigma and the health of lesbian, gay, and bisexual populations. Current Directions in Psychological Science, 23, 127-132.

20.

Hatzenbuehler

M. L.

Corbin

W. R.

Fromme

(2008). Trajectories and determinants of alcohol use among LGB young adults and their heterosexual peers: Results from a prospective study. Developmental Psychology, 44, 81-90.

21.

Heckathorn

D. D.

Cameron

C. J.

(2017). Network sampling: From snowball and multiplicity to respondent-driven sampling. Annual Review of Sociology, 43, 101-119.

22.

Hendricks

M. L.

Testa

R. J.

(2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43, 460-467.

23.

Hoffman

(2014). An overview of depression among transgender women. Depression Research and Treatment, 2014, 1-9.

24.

Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press.

25.

Jauk

(2013). Gender violence revisited: Lessons from violent victimization of transgender identified individuals. Sexualities, 16, 807-825.

26.

Katz-Wise

S. L.

Budge

S. L.

Orovecz

J. J.

Nguyen

Nava-Coulter

Thomson

(2017). Imagining the future: Perspectives among youth and caregivers in the trans youth family study. Journal of Counseling Psychology, 64, 26-40.

27.

Kozee

H. B.

Tylka

T. L.

Bauerband

(2012). Measuring transgender individuals’ comfort with gender identity and appearance: Development and validation of the Transgender Congruence Scale. Psychology of Women Quarterly, 36, 179-196.

28.

Levitt

H. M.

Ippolito

M. R.

(2013). Being transgender: Navigating minority stressors and developing authentic self-presentation. Psychology of Women Quarterly, 38, 46-64.

29.

Meyer

(2012). An intersectional analysis of lesbian, gay, bisexual, and transgender (LGBT) people’s evaluations of anti-queer violence. Gender & Society, 26, 849-873.

30.

Meyer

I. H.

(2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697.

31.

Meyer

I. H.

(2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. The Counseling Psychologist, 38, 442-454.

32.

Nuttbrock

Bockting

Rosenblum

Hwahng

Mason

Macri

Becker

(2014a). Gender abuse, depressive symptoms, and substance use among transgender women: A 3-year prospective study. American Journal of Public Health, 104, 2199-2206.

33.

Nuttbrock

Bockting

Rosenblum

Hwahng

Mason

Macri

Becker

(2014b). Gender abuse and major depression among transgender women: A prospective study of vulnerability and resilience. American Journal of Public Health, 104, 2191-2198.

34.

Obedin-Maliver

Goldsmith

Stewart

White

Tran

Brenman

. . . Lunn

(2011). Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. Journal of the American Medical Association, 306, 971-977.

35.

Reisner

S. L.

Deutsch

M. B.

Bhasin

Bockting

Brown

G. R.

Feldman

. . . Goodman

(2016). Advancing methods for US transgender health research. Current Opinion in Endocrinology, Diabetes and Obesity, 23, 198-207.

36.

Reisner

S. L.

Poteat

Keatley

J. A.

Cabral

Mothopeng

Dunham

. . . Baral

S. D.

(2016). Global health burden and needs of transgender populations: A review. The Lancet, 388, 412-436.

37.

Ross

L. E.

Doctor

Dimito

Kueho

Armstrong

M. S.

(2007). Can talking about oppression reduce depression? Modified CBT group treatment for LGBT people with depression. Journal of Gay & Lesbian Social Services, 19, 17-34.

38.

Serano

(2016). Whipping girl: A transsexual woman on sexism and the scapegoating of femininity (2nd ed.). Berkeley, CA: Seal Press.

39.

Sevelius

J. M.

(2013). Gender affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles, 68, 675-689.

40.

Shulman

G. P.

Holt

N. R.

Hope

D. A.

Mocarski

Eyer

Woodruff

(2017). A review of contemporary assessment tools for use with transgender and gender nonconforming adults. Psychology of Sexual Orientation & Gender Diversity, 4, 304-313.

41.

Singh

A. A.

(2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68, 690-702.

42.

Singh

A. A.

McKleroy

V. S.

(2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender people of color who have survived traumatic life events. Traumatology, 17(2), 34-44.

43.

Stockings

Degenhardt

Lee

Y. Y.

Mihalopoulos

Liu

Hobbs

Patton

(2015). Symptom screening scales for detecting major depressive disorder in children and adolescents: A systematic review and meta-analysis of reliability, validity and diagnostic utility. Journal of Affective Disorders, 174, 447-463.

44.

Stotzer

R. L.

(2009). Violence against transgender people: A review of United States data. Aggression and Violent Behavior, 14, 170-179.

45.

Stotzer

R. L.

(2017). Data sources hinder our understanding of transgender murders. American Journal of Public Health, 107, 1362-1363.

46.

Testa

R. J.

Habarth

Peta

Balsam

Bockting

W. O.

(2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation & Gender Diversity, 2, 65-77.

47.

Testa

R. J.

Michaels

M. S.

Bliss

Rogers

M. L.

Balsam

K. F.

Joiner

(2017). Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. Journal of Abnormal Psychology, 126, 125-136.

48.

Testa

R. J.

Sciacca

L. M.

Wang

Hendricks

M. L.

Goldblum

Bradford

Bongar

(2012). Effects of violence on transgender people. Professional Psychology: Research and Practice, 43, 452-459.

49.

The GenIUSS Group. (2014). Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Los Angeles, CA: The Williams Institue.

50.

Thompson

(2015). Hamilton Rating Scale for Anxiety (HAM-A). Occupational Medicine, 65, Article 601.

51.

White Hughto

J. M.

Reisner

S. L.

Pachankis

J. E

. (2015). Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Social Science & Medicine, 147, 222-231.

52.

Xavier

J. M.

Bobbin

Singer

Budd

(2005). A needs assessment of transgendered people of color living in Washington, DC. International Journal of Transgenderism, 8(2-3), 31-47.