Rain Before Rainbows: The Science of Transgender Flourishing

“We’re all born naked and the rest is drag”: That pithy tagline, popularized by RuPaul of RuPaul’s Drag Race fame, sums up the socially constructed nature of gender in just a handful of words, though it’s far from the full picture. Philosopher Judith Butler’s concept of gender performativity fills in the gaps. In this performance, wrote Thekla Morgenroth (University of Exeter, United Kingdom) and Michelle K. Ryan (University of Exeter and University of Groningen) in Perspectives on Psychological Science, each of us plays a character (most often, a man or a woman) through our costume and behavioral scripts. The performance takes place on a stage set by our cultural environments for an audience of others and ourselves. 

“The concept of gender is created through the performance of gender—the way that we act in line with gender norms,” Morgenroth added in an interview with the Observer. Recognizing the socially constructed nature of this performance, they said, can help everyone to live safer and more authentic lives. 

In this episode of Under the Cortex, Thekla Morgenroth (University of Exeter in the United Kingdom) discusses how the sex/gender binary is perpetuated and disrupted.

Generally, we view this performance as essential to who we are as individuals, Morgenroth and Ryan noted, and, in most modern Western societies, the cultural stage is set to perpetuate a rigid sex/gender binary in which all males are men, all females are women, and all people are expected to dress and behave in certain ways as a result. This binary is culturally enforced by our laws, languages (through gendered pronouns and nouns—e.g., “he” and “she” in English or “un étudiant” and “une étudiante” for “a student” in French), and even our architecture (as with gender-segregated bathrooms), in addition to broader cultural ideas about masculine and feminine gender roles. 

When a person’s performance is out of alignment with this binary, Morgenroth and Ryan added, they cause “gender trouble”—a term coined by Butler. This can occur when someone plays the “wrong” character (e.g., a nonbinary or transgender person), puts on an “incongruent” costume (e.g., a woman wearing pants in 19th-century America), or enacts an “incorrect” script (e.g., a man who wants to be a stay-at-home father). 

Gender trouble is common even among the majority of people who are cisgender (that identify with the gender they were assigned at birth), Morgenroth and Ryan note, but it is most harshly punished in people who are LGBTQ+, and especially in people who are transgender—people that have a gender other than the binary option they were assigned at birth or, in the case of some nonbinary people, no gender at all.  

“Trans and nonbinary people, particularly those of color, often get particularly negative reactions because they disrupt the gender/sex binary basically by just existing,” Morgenroth said. 

Challenging the binary in this way can be met with everything from derision to imprisonment or violence, a chilling reality for the 33 transgender or nonbinary people, many of them women of color, who have been murdered in the United States alone this year, according to the Human Rights Campaign (which notes that many of these deaths go unreported or misreported). In the 2015 U.S. Transgender Survey (USTS), almost one in 10 respondents reported being physically attacked because they were transgender, with rates as high as 19% for those who were Native American and 23% for those who were undocumented immigrants. 

This kind of violence arises at least in part because gender trouble can trigger feelings of threat, Morgenroth and Ryan explained. When someone perceives another person’s gender variance as threatening the sense of certainty and belonging provided by a binary view of man- or womanhood, they may attempt to enforce their binary perspective through social shaming, economic penalties, open hostility, or physical violence. 

The legal system can also be used to serve these ends: As of April 15th, lawmakers in at least 33 U.S. states had introduced a total of 100 bills in 2021 intended to strip trans people of their right to body autonomy and equality. These bills include bans on trans athletes’ participation in school sports; opt-in-only or opt-out options for curricula that include mention of LGBTQ people; protections for insurance carriers and health care providers that refuse coverage or care to transgender people; and prohibitions on the evidence-based use of hormones and puberty blockers for children who are transgender, including penalties of up to 10 years in prison for doctors who provide these treatments. Perhaps most disturbingly, legislators in New Hampshire and Texas have put forward bills that would define gender-affirming care as child abuse, potentially allowing trans kids to be forcibly removed from their homes or their parents to be imprisoned. 

“Regardless of whether these pieces of legislation pass, the fact that they are even being considered suggests just how disposable we are considered to be,” wrote artist Alok Vaid-Menon of similar bills in their 2020 book, Beyond the Gender Binary. “At a fundamental level, we are still having to argue for the very ability to exist.”  

In this transphobic climate, it’s no surprise that elevated rates of suicidal ideation and suicide attempts have been found in trans communities across the world. 

Through the 2015 USTS, Sandy James (National Center for Transgender Equality) and colleagues found that, of 27,715 transgender respondents, 81% had seriously considered suicide and 41% had made at least one attempt in their lifetime, compared to 4.6% of the general population; within the past year, 48% had experienced suicidal ideation and 7% had attempted suicide. 

Among a sample of 1,309 trans men and women in China, Runsen Chen (Central South University, China) and colleagues found that 56% of participants reported considering suicide, and 16% had made an attempt in their lifetime, compared to 12% and 3%, respectively, in the general Chinese population. Over half the participants also reported experiencing major depressive disorder at some point in their lives. 

Looking at a much smaller time scale, a 2017 study of 937 transgender women in eight countries in sub-Saharan Africa (Burkina Faso, Côte d’Ivoire, the Gambia, Lesotho, Malawi, Senegal, Swaziland, and Togo) reported similar rates of depressive symptoms (57%), and 19% of participants had considered suicide in the past 2 weeks alone. Notably, this region is home to more than 70% of the world’s HIV cases, according to Tonia Poteat (Johns Hopkins Bloomberg School of Public Health) and colleagues. During the study, HIV-positive rates were twice as high among transgender women compared to cisgender gay and bisexual men, and transgender women who reported experiencing depression, violence, and stigma from law enforcement were particularly likely to test positive. 

The risk for death by suicide in a Dutch sample of 8,263 people referred to a gender clinic between 1972 and 2017 was 3 to 4 times higher than in the general population, according to a 2020 study by Chantal M. Wiepjes (VU University Amsterdam) and colleagues. It can be difficult to track fatality rates within the trans community outside of this kind of clinical context, however, because gender identity is rarely recorded on death certificates, as Ann P. Haas (City University of New York) and colleagues noted in a call for more thorough demographic reporting.  

This misery is far from inevitable. Even well-meaning attempts to address transgender health disparities can fall into the trap of depicting gender variance as a modern phenomenon, but a look back across human history—or even just outside mainstream Western culture today—suggests this is not the case. In hir 1996 book Transgender Warriors, labor activist Leslie Feinberg demonstrated that people we might call “transgender” today have always been with us. They include, for example, the two-spirit people recognized by certain North American indigenous groups, such as Lakota winyanktecha, as well as hijras in India and Pakistan and faʻafafine in Samoan culture. 

These “third-gender” people—who have social roles unique to their own cultures, distinct from being transgender or nonbinary—were and in some places still are valued and respected members of their societies, Feinberg noted, belying the idea that the social stigma and violence faced by gender-minority people today is inherent either to gender variance or to human nature. What changed, Feinberg stressed, is how European colonialism and capitalism have restricted the ways in which people outside of the gender binary can safely exist. 

The cause of this suffering, in other words, is transphobic bias, and the simple solution, as demonstrated by trans people’s own experience and a growing body of psychological science, is acceptance and autonomy. 

Social support for a sunnier start 

In a 2019 study of 129 Americans ages 15 to 21, Stephen T. Russell (University of Texas at Austin) and colleagues found that transgender participants who were able to go by their chosen name in at least one social context (home, school, work, or with friends) were 29% less likely to report suicidal ideation and 56% less likely to report suicidal behavior in the past year.  

Similarly, in 2020, the Trevor Project conducted a U.S. survey of 40,000 LGBTQ+ youth ages 13 to 24, approximately 13,600 of whom were transgender or nonbinary. The survey found that young people who reported having their pronouns respected by all or most people in their lives were less than half as likely to report attempting suicide in the past year (12%) than those who had no such support (28%). 

Parental support is an especially influential factor, noted Robb Travers (Wilfrid Laurier University, Canada) and colleagues in a 2012 Trans PULSE report. Through a survey of 433 trans participants ages 16 to 24 in Canada, the researchers found that more than 70% of youth who perceived their parents as strongly supportive of their gender reported being satisfied with their lives and mental health; by comparison, among youth whose parents were less supportive or not at all supportive, just 33% were satisfied with their lives, and only 15% reported positive mental health. The majority of trans youth without strong parental support also reported considering (60%) and even attempting suicide (57%) in the past year. 

Youth in the Trans PULSE survey with supportive home environments still experienced heightened suicidal ideation compared to the general population, but just 4% reported attempting suicide in the past year—a 93% reduction in suicide attempts. 

“While some parents worry that being trans will cause their child to be unhappy, ultimately our data indicate that it is parents and caregivers themselves who provide the foundation for their children’s health and well-being with their support.”

Robb Travers (Wilfrid Laurier University, Canada) and colleagues

These findings are echoed throughout the literature. In a 2017 study of 310 children in the United States and Canada, Lily Durwood (Harvard University) and APS Fellows Katie A. McLaughlin (Harvard University) and Kristina R. Olson (Princeton University) found that transgender kids whose parents allowed them to socially transition (by dressing how they wanted and using their chosen name and pronouns) reported rates of depression in line with those of their cisgender siblings and age-matched peers. Furthermore, in a 2021 study of 265 transgender youth ages 3 to 15, Durwood, McLaughlin, Olson, and colleagues found that children whose parents reported higher levels of support for their child among family, friends, and at school also reported levels of anxiety and depression similar to those found in the general population of children. 

In the Trans PULSE survey, participants who described their parents as only somewhat supportive did not report significantly better outcomes than those whose parents were not at all supportive, Travers and colleagues noted. This, the researchers wrote, suggests that anything less than the same support parents would extend to a cisgender child is likely to negatively impact well-being. No youth with strongly supportive parents reported experiencing homelessness or other issues with housing security, for example, compared to 55% of those with less supportive parents, who are more likely to run away from or be forced out of their childhood homes, and to lack financial support from family for housing. 

“While some parents worry that being trans will cause their child to be unhappy, ultimately our data indicate that it is parents and caregivers themselves who provide the foundation for their children’s health and well-being with their support,” Travers and colleagues wrote. 

Fortunately, although not all trans youth can count on support from the people they were born to, family can be something you find, too. In the Trevor Project’s 2020 survey, young people who reported that they were highly supported by at least one friend or were able to access at least one LGBTQ-affirming space in their community were 8% less likely to have attempted suicide in the past year. 

Scattering storm clouds in adulthood 

No one stays young forever, and social support forms the foundation of mental health in adulthood as well. 

In a 2018 study of 423 transgender and nonbinary adults ages 18 to 61 in Brazil, Bruna L. Seibel (Faculdade Cesuca University, Brazil) and colleagues found that participants who described their parents as being at least somewhat supportive of their gender reported levels of self-esteem in line with the general population. By contrast, not only did participants without parental support report lower self-esteem, they were also more than 4 times more likely to have moved away from friends and family because they were transgender, and they were significantly more likely to have experienced homelessness as a result.  

The ability to work openly as a transgender person without facing harassment or other forms of discrimination becomes increasingly important with age as well. In the 2015 National Center for Transgender Equality survey of 28,000 transgender Americans, participants were 3 times more likely to be unemployed than the national average, and more than twice as likely as cisgender people to live below the poverty line, with 29% making less than $12,000 annually. 

In line with this economic hardship, 13% of respondents reported that they had lost at least one job in their lifetime because of their gender. Of those who had been employed in the past year, 14% had been verbally harassed at work because they were transgender, and the majority (77%) had to hide their gender, quit their job, or take other steps to escape mistreatment at their workplace. 

Of course, it doesn’t have to be this way. In a 2015 reanalysis of data collected from 1,299 transgender adults in 2003, Amaya Perez-Brumer (Columbia University) and colleagues found that participants were less likely to have attempted suicide in their lifetime in areas with lower state-level structural stigma. The study focused on the presence or absence of policies supporting LGB people (e.g., legal marriage and adoption for same-sex couples; employment-nondiscrimination and hate-crime statutes that include sexual orientation), Perez-Brumer and colleagues noted, because legal protections for gender-minority people were rare when the data were collected. States with stronger legal protections for LGB people have consistently gone on to have more protections for gender minorities, the authors added, which suggests that these policies may serve as historic indicators of current support or future support for people who are transgender. 

Similarly, in a 2021 reanalysis of data collected from 6,771 transgender people in the European Union in 2012, Richard Bränström (Karolinska Institutet, Sweden) and colleagues found that lower transphobic structural stigma at the national level (including legal protections against discrimination, marriage recognition for transgender people, legal gender recognition, and the ability to claim asylum on the basis of gender identity) were significantly associated with higher life satisfaction. 

In the workplace, employers can help to create a trans-inclusive environment by having clear policies about respecting colleagues’ pronouns, names, and appearance, in addition to their right to use shared spaces such as bathrooms, wrote Christian N. Thoroughgood (Villanova University) and colleagues in the Harvard Business Review. It’s also important to “proactively cultivate a supportive work environment” so that trans employees don’t have to build one themselves from scratch, the authors added, by modeling trans-inclusive behavior and having a clear process for trans employees to address questions and concerns with management. 

“Only when people feel totally authentic and connected with their organizations can they achieve their full potential at work. Trans employees are no exception,” Thoroughgood and colleagues concluded. 

Finding community can powerfully influence the well-being of people who are transgender in adulthood as well. In a review of 18 studies from the United States, Canada, Croatia, Guatemala, and the United Kingdom, Athena D. F. Sherman (Johns Hopkins University) and colleagues found that trans adults who reported higher participation in the trans community, either in person, online, or through media such as television and movies, also reported better mental well-being. In one study of 1,093 trans men and women in the United States, for example, those who had peer support from other people in the trans community experienced less psychological distress in response to transphobic stigma. 

The freedom to grow 

Mainstream narratives often portray medically transitioning as a prerequisite for being transgender, but one is not necessarily dependent on the other. According to the 2015 USTS, for example, the desire to receive hormone therapy was reported by 95% of transgender men and women but just 49% of nonbinary people.  

The need for surgical intervention also differs significantly by gender and the procedure in question. The majority of transgender women and nonbinary people assigned male at birth (AMAB) reported wanting or having had hair removal, for example, and virtually all transgender men and the majority of nonbinary people assigned female at birth (AFAB) wanted or had already had chest-reduction surgery. 

But other surgeries are both less common and less wanted, particularly among nonbinary people. More than 75% of transgender women and 60% of transgender men reported wanting, having had, or considering some form of genital reconstructive surgery, whereas roughly 50% of AMAB and 70% of AFAB nonbinary people were certain they did not want it. Nearly all trans men but only 67% of AFAB nonbinary people wanted, had, or were considering having a hysterectomy. 

Regardless of how common these procedures may or may not be, medical interventions such as hormones and gender-affirming surgery can be lifesaving for the people who need them. 

In a 2021 study that leveraged data from the 2015 USTS, for example, Anthony N. Almazan (Harvard Medical School) and Alex S. Keuroghlian (Massachusetts General Hospital) found that participants who reported undergoing at least one form of gender-affirming surgery in the past 2 years were less than half as likely to report experiencing suicidal ideation or attempting suicide in the past year or experiencing other forms of severe psychological distress in the past month than respondents who reported wanting but not receiving surgery. When Jack L. Turban (Harvard Medical School) and colleagues reexamined the USTS data in 2020, they found that adults who reported wanting and receiving puberty blockers as a child or adolescent were 15% less likely to report suicidal ideation in their lifetime or the past year. 

Likewise, in a 2021 review of 20 studies on the relationship between hormone therapy and mental health, Kellan E. Baker (Johns Hopkins Bloomberg School of Public Health) and colleagues concluded that hormone therapy decreased participants’ depression and anxiety and improved their quality of life—though the strength of these associations was limited by small sample sizes. 

Anna Martha Vaitses Fontanari (Federal University of Rio Grande do Sul) and colleagues reported similar findings from a study of 350 Brazilian transgender and nonbinary youth. In this case, youth who were able to take multiple steps toward gender affirmation, including socially, legally, and medically transitioning, reported fewer symptoms of depression and anxiety and were more likely to report feeling socially accepted and positive about their gender. 

Of note, a 2021 meta-analysis of 27 studies of 7,928 participants age 13 or older who underwent gender-affirming surgery in Belgium, Brazil, Canada, Germany, Italy, the Netherlands, Singapore, the United Kingdom, and the United States found that just 1% of participants reported regretting their physical transition for any reason between 1 and 9 years after the fact. Less than half of that 1% reported wanting to detransition or already having done so, either because they wanted to return to their previous binary state or had realized that they were nonbinary, Valeria Bustos (University of Pittsburgh, USA) and colleagues wrote. 

More often than not, the researchers added, those who experienced regret reported that it stemmed from postsurgery transphobia among family, friends, and employers rather than a change in their gender or change of heart about the surgery itself. 

Pulling the weeds: Depathologizing transness 

Despite the clear benefits, very few transgender people are able to access gender-affirming medical care because of economic constraints and transphobic bias on the part of practitioners and insurance carriers. 

Although Brazil provides its citizens with access to trans health care as part of its universal health program, Fontanari and colleagues noted, clinics that provide these treatments are not equally distributed throughout the country, creating geographic barriers to care. 

In countries without this kind of inclusive social safety net, including the United States, the barriers to care are even more severe. In the 2015 USTS, 14% of respondents were uninsured; even among those who had insurance, one out of four people looking to receive gender-affirming hormones and more than half of people seeking transition-related surgery were denied coverage. According to the gender-confirmation fundraising guide on GoFundMe—a platform Americans sometimes turn to in order to pay for lifesaving health care, including insulin and even cancer treatment—hormone-replacement therapy can cost hundreds to thousands of dollars annually, and gender-affirming surgeries may cost thousands or tens of thousands of dollars per procedure for those without insurance. 

Given these and other barriers, although 91% of USTS respondents reported needing some form of health care related to being transgender, only 65% had received any form of counseling (54%), hormone therapy (49%), surgery (25%), or puberty blockers (1%) in their lifetime. 

Accessing trans-related health care also often requires people to submit to a lengthy diagnostic process, wrote researcher Florence Ashley (University of Toronto), author of the 2019 article “The Misuse of Gender Dysphoria” in Perspectives on Psychological Science. 

“Our experience of gender is no more or less pathological than that of ‘mainstream’ society . . . We have a right to live in a body that matches our self-image and deep desires without someone else being the gatekeeper to our experience.” 

Florence Ashley (University of Toronto, Canada)

The diagnosis of “transsexualism”—a term that, in this context, positioned being transgender as a mental illness—first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Since then, Ashley wrote, advocates efforts to destigmatize being transgender have resulted in a number of shifts in terminology, including the relatively recent removal of “gender identity disorder” in favor of “gender dysphoria” in the DSM-V in 2013 and “gender incongruence” in the 11th revision of the International Classification of Diseases in 2019. Gender dysphoria in particular, though inconsistently defined in the academic literature, tends to be diagnosed on the basis of the emotional distress a person might experience as a result of misalignment between their gender and the sex or gender role they were assigned at birth, Ashley explained. 

Nonetheless, they said, for people who view being transgender as an uncommon but nonpathological part of human variation, any kind of diagnostic process can be distressing and dehumanizing because it gives practitioners the authority to decide whether a person is “trans enough” to receive care instead of respecting that person’s self-knowledge and autonomy.  

“Health care practitioners often falsely believe that a diagnosis of gender dysphoria under the DSM-V is required before initiating hormone therapy or offering transition-related surgeries,” Ashley explained, but this isn’t the case everywhere. They emphasized that although a diagnosis may be necessary when required for insurance coverage, for a surgical referral, or by local legislation, this should be determined on a case-by-case basis rather than being an automatic response to a person being transgender. 

Mental health issues are common among trans people, Ashley added, but, as demonstrated above, they occur as a by-product of stigma, not transness itself. 

“The pathologization of trans identity came about because of the prejudices of psychiatrists and psychologists towards gender nonconformity, and continues to bolster the stigmatization of trans people today,” Ashley wrote. 

Instead of seeking to define right and wrong, normal and abnormal, they added, mental health professionals need to start thinking about diagnoses in terms of how they benefit the population in question. Labeling gender dysphoria—or simply being transgender—as a mental illness has never been about achieving the best outcomes for transgender people themselves, Ashley continued, but about stigmatizing trans people in order to create barriers to gender-affirming health care and participation in society. 

“Our experience of gender is no more or less pathological than that of ‘mainstream’ society,” they said. “We have a right to live in a body that matches our self-image and deep desires without someone else being the gatekeeper to our experience.” 

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