Abstract
Introduction
One way that transgender and gender diverse (TGD) people may affirm their gender is through a legal name and/or gender marker change. Legal gender affirmation is associated with less psychological distress, but research has yet to expand upon the mechanisms that may help explain this association. We examined associations between legal gender affirmation, psychological distress, and physical health in TGD people, as well as the mediating effect of exposure to enacted stigma.
Methods
Data are from the baseline portion of a longitudinal mixed-methods study of how sociopolitical contexts influence marginalization, health, and resilience for TGD people. The study included 158 TGD participants from Oregon, Michigan, Nebraska, and Tennessee. Baseline data were collected September 2019–March 2020 (the overall study concluded Fall 2021).
Results
Latent variable structural equation model analyses revealed that participants who had legally affirmed their gender reported less enacted stigma, which was associated with less psychological distress and physical health issues. There was a significant indirect effect via enacted stigma, such that this variable may partially help explain why legal gender affirmation is associated with better health outcomes.
Conclusions
Legal gender affirmation is likely to influence TGD people’s health and well-being by shaping exposure to minority stress—specifically, enacted stigma. Our findings demonstrate the importance of sociopolitical factors in health outcomes for TGD people.
Policy Implications
Given the health benefits of legal gender affirmation and the potential protection from enacted stigma, policies should be revised to make legal name and/or gender marker changes more accessible for TGD people.
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References
Brooks, V. R. (1981). Minority stress and lesbian women. Lexington Books.
Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., Amtmann, D., Bode, R., Buysse, D., Choi, S., Cook, K., DeVellis, R., DeWalt, D., Fries, J. F., Gershon, R., Hahn, E. A., Lai, J. -S., Pilkonis, P., Revicki, D., & Hays, R. (2010). The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology, 63(11), 1179–1194. https://doi.org/10.1016/j.jclinepi.2010.04.011
Currah, P. (2022). Sex is as sex does: governing transgender identity. NYU Press.
DeChants, J. P., Price, M. N., Green, A. E., Davis, C. K., & Pick, C. J. (2022). Association of updating identification documents with suicidal ideation and attempts among transgender and nonbinary youth. International Journal of Environmental Research and Public Health, 19(9), 1–9. https://doi.org/10.3390/ijerph19095016
Dolan, I. J., Strauss, P., Winter, S., & Lin, A. (2020). Misgendering and experiences of stigma in health care settings for transgender people. Medical Journal of Australia, 212(4), 150. https://doi.org/10.5694/mja2.50497
DuBois, L. Z. (2012). Associations between transition-specific stress experience, nocturnal decline in ambulatory blood pressure, and C-reactive protein levels among transgender men. American Journal of Human Biology, 24(1), 52–61. https://doi.org/10.1002/ajhb.22203
DuBois, L. Z., & Juster, R.-P. (2022). Lived experience and allostatic load among transmasculine people living in the United States. Psychoneuroendocrinology, 143, 105849. https://doi.org/10.1016/j.psyneuen.2022.105849
DuBois, L. Z., Powers, S., Everett, B. G., & Juster, R.-P. (2017). Stigma and diurnal cortisol among transitioning transgender men. Psychoneuroendocrinology, 82, 59–66. https://doi.org/10.1016/j.psyneuen.2017.05.008
Factor, R., & Rothblum, E. (2008). Exploring gender identity and community among three groups of transgender individuals in the United States: MTFs, FTMs, and genderqueers. Health Sociology Review, 17(3), 235–253. https://doi.org/10.5172/hesr.451.17.3.235
Garcia, J., & Crosby, R. A. (2020). Social determinants of discrimination and access to health care among transgender women in Oregon. Transgender Health, 5(4), 225–233. https://doi.org/10.1089/trgh.2019.0090
Goldenberg, T., Reisner, S., Harper, G. W., Gamarel, K. E., & Stephenson, R. (2020). State-level transgender-specific policies, race/ethnicity, and use of medical gender affirmation services among transgender and other gender-diverse people in the United States. The Milbank Quarterly, 98(3), 802–846. https://doi.org/10.1111/1468-0009.12467
Hill, B. J., Crosby, R., Bouris, A., Brown, R., Bak, T., Rosentel, K., VandeVusse, A., Silverman, M., & Salazar, L. (2018). Exploring transgender legal name change as a potential structural intervention for mitigating social determinants of health among transgender women of color. Sexuality Research and Social Policy, 15(1), 25–33. https://doi.org/10.1007/s13178-017-0289-6
James, Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 US Transgender Survey. National Center for Transgender Equality.
Kenny, D. A. (2017, February). MedPower: An interactive tool for the estimation of power in tests of mediation [Computer software]. Available from https://davidakenny.shinyapps.io/MedPower/.
King, W. M., & Gamarel, K. E. (2021). A scoping review examining social and legal gender affirmation and health among transgender populations. Transgender Health, 6(1), 5–22. https://doi.org/10.1089/trgh.2020.0025
King, W. M., Hughto, J. M. W., & Operario, D. (2020). Transgender stigma: A critical scoping review of definitions, domains, and measures used in empirical research. Social Science & Medicine, 250, 112867. https://doi.org/10.1016/j.socscimed.2020.112867
Knudson, G., Green, J., Tangpricha, V., Ettner, R., Bouman, W. P., Adrian, T., Allen, L., De Cuypere, G., Fraser, L., Hansen, T. M., Karasic, D., Kreukels, B. P. C., Rachlin, K., Schechter, L., Winter, S., & on behalf of the WPATH Executive Committee and Board of Directors. (2018). Identity recognition statement of the world professional association for transgender health (WPATH). International Journal of Transgenderism, 19(3), 355–356. https://doi.org/10.1080/15532739.2018.1470399
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258–266.
Lacombe-Duncan, A., Jadwin-Cakmak, L., Trammell, R., Burks, C., Rivera, B., Reyes, L., Abad, J., Ward, L., Harris, H., Harper, G. W., & Gamarel, K. E. (2021). “…everybody else is more privileged. then it’s us…”: A qualitative study exploring community responses to social determinants of health inequities and intersectional exclusion among trans women of color in Detroit, Michigan. Sexuality Research and Social Policy. https://doi.org/10.1007/s13178-021-00642-2
Loza, O., Beltran, O., Perez, A., & Green, J. (2021). Impact of name change and gender marker correction on identity documents to structural factors and harassment among transgender and gender diverse people in Texas. Sexuality, Gender & Policy, 4(2), 76–105. https://doi.org/10.1002/sgp2.12035
Malta, M., LeGrand, S., Turban, J., Poteat, T., & Whetten, K. (2020). Gender-congruent government identification is crucial for gender affirmation. The Lancet Public Health, 5(4), e178–e179. https://doi.org/10.1016/S2468-2667(20)30054-2
Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 16.
Puckett, J. A., Aboussouan, A. B., Ralston, A. L., Mustanski, B., & Newcomb, M. E. (2021). Systems of cissexism and the daily production of stress for transgender and gender diverse people. International Journal of Transgender Health. Advanced online publication: https://doi-org.proxy1.cl.msu.edu/. https://doi.org/10.1080/26895269.2021.1937437
Puckett, J. A., Price, S. F., Mocarski, R., Mustanski, B., & Newcomb, M. E. (2022a). Transgender and gender diverse individuals’ daily experiences of rumination. American Journal of Orthopsychiatry. Advance Online Publication: https://doi.org/10.1037/ort0000636
Puckett, J. A., Tornello, S., Mustanski, B., & Newcomb, M. E. (2022b). Gender variations, generational effects, and mental health of transgender people in relation to timing and status of gender identity milestones. Psychology of Sexual Orientation and Gender Diversity, 9(2), 165–178. https://doi.org/10.1037/sgd0000391
Reisner, S. L., Radix, A., & Deutsch, M. B. (2016). Integrated and gender-affirming transgender clinical care and research. Journal of Acquired Immune Deficiency Syndromes, 72, S235-242. https://doi.org/10.1097/QAI.0000000000001088
Restar, A., Jin, H., Breslow, A., Reisner, S. L., Mimiaga, M., Cahill, S., & Hughto, J. M. W. (2020). Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations. SSM - Population Health, 11, 100595. https://doi.org/10.1016/j.ssmph.2020.100595
Scheim, A. I., Perez-Brumer, A. G., & Bauer, G. R. (2020). Gender-concordant identity documents and mental health among transgender adults in the USA: A cross-sectional study. The Lancet Public Health, 5(4), e196–e203. https://doi.org/10.1016/S2468-2667(20)30032-3
Schumacker, R. E., & Lomax, R. G. (2010). A beginner’s guide to structural equation modeling, 3rd ed. Routledge/Taylor & Francis Group.
Smart, B. D., Mann-Jackson, L., Alonzo, J., Tanner, A. E., Garcia, M., Refugio Aviles, L., & Rhodes, S. D. (2020). Transgender women of color in the U.S. South: A qualitative study of social determinants of health and healthcare perspectives. International Journal of Transgender Health, 1–24. https://doi.org/10.1080/26895269.2020.1848691
Steadman, S. (2021). “That name is dead to me”: Reforming name change laws to protect transgender and nonbinary youth. University of Michigan Journal of Law Reform, 55. https://doi.org/10.36646/mjlr.55.1.that
Tan, K. K. H., Watson, R. J., Byrne, J. L., & Veale, J. F. (2022). Barriers to possessing gender-concordant identity documents are associated with transgender and nonbinary people’s mental health in Aotearoa/New Zealand. LGBT Health. https://doi.org/10.1089/lgbt.2021.0240
Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. https://doi.org/10.1037/sgd0000081
Wentling, T. (2020). Contested citizenship: Renaming processes among people of transgender experience. Journal of Homosexuality, 67(12), 1653–1674. https://doi.org/10.1080/00918369.2019.1610634
World Health Organization. (2015). Transgender people and HIV: Policy brief. World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/179517/WHO_HIV_2015.17_eng.pdf?sequence=1&isAllowed=y
Xavier, J., Bradford, J., Hendricks, M., Safford, L., McKee, R., Martin, E., & Honnold, J. A. (2013). Transgender health care acccess in Virginia: A qualitative study. International Journal of Transgenderism, 14, 3–17. https://doi.org/10.1080/15532739.2013.689513
Yee, K., Lind, B. K., & Downing, J. (2022). Change in gender on record and transgender adults’ mental or behavioral health. American Journal of Preventive Medicine, 62(5), 696–704. https://doi.org/10.1016/j.amepre.2021.10.016
Acknowledgements
We would like to thank the members of the community board associated with Trans Collaborations in Nebraska for their thoughtful feedback. We also deeply appreciate the time of all the participants who contributed to this study. This study also would not have been possible without the many dedicated research team members across all sites. We wish to thank T. Zachary Huit, Brenna R. Lash, Tian Walker, Natalie Holt, Allura Ralston, Makinna Miles, A. Capannola, Clove Tipton, Geeta Eick, Bex Macfife, Holly Moulton, Lindsey Foltz, Kelsi Kuehn, Oliver Hoover, Jaden Haun, Beyla Geoffrey, Alex Jagielski, Julia Rohrabaugh, Lauren King Watt, Felix Hart, Rin Nguyen, Maryam Razzaq, Belle Andrus, Kalei Glozier, Rowan Giffel, Felix Brown, Taylor Anderson, Callie Harris, Megan Wertz, Heather Barnes, Sage Volk, Lex Pulice-Farrow, and Drs. Kirsten Gonzalez, Jennifer Jabson-Tree, and Cindi StrutzStreetharan for their involvement in this work.
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Jae A. Puckett and L. Zachary DuBois conceptualized and led the overarching study. Jae A. Puckett led data analysis for this manuscript. Sarah Price, Terra Dunn, Kelsi Kuehn, Devon Kimball, and L. Zachary DuBois contributed to original writing and all co-authors were involved in editing the manuscript. All authors approved the final manuscript.
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Puckett, J.A., Price, S., Dunn, T. et al. Legal Gender Affirmation, Psychological Distress, and Physical Health Issues: Indirect Effects via Enacted Stigma. Sex Res Soc Policy (2024). https://doi.org/10.1007/s13178-024-00971-y
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DOI: https://doi.org/10.1007/s13178-024-00971-y