“I wanted to say this is great that you are doing this!  I have talked with other trannies about whether the rate of mental illness in the trans community was particularly high, or if it is just our friends who are loony.“

We cannot answer whether people who are trans+/SOFFAs have a higher rate of mental illness than do non-trans people, both because we did not have many non-trans people answer and because it is entirely possible that those with no mental health issues chose to skip a survey entitled, “Mental Health Survey.”  However, among those who did answer, the results are stunning. 

• Three-quarters have at least considered suicide.
• Two-thirds have had two or more mental illness diagnoses.
• Two-thirds are or have been depressed; nearly half have had an anxiety disorder, and a third have post-traumatic stress disorder.
• Nearly 18% have a current mental health condition they rate as “debilitating.”
• Most say their mental health condition is/was at least partially related to being trans+/SOFFA.
• Thirty percent (30%) have had treatment forced upon them.

On the positive side,

• Seventy percent (70%) of those with a long-term condition found that starting hormones improved the condition.
• Most of us have multiple techniques for improving or maintaining our mental health.
• Almost half of us have mental health insurance coverage.

Read on for more details.

Who Responded

Ninety-six (96) individuals answered our 19-item survey.  The vast majority – 78% (N=75) – indicated explicitly or through their comments that they were or had been trans.  Thirteen (13%) were non-trans significant others (several of these checked additional identities, as well).  Four were non-trans friends or allies, and four did not check any of our demographics boxes. 

Although we did not specifically ask whether trans+ respondents were male-to-female (MTF) or female-to-male (FTM), the sources of the survey returns and comments made suggest the vast majority was FTM.

Six respondents said they were helping professionals themselves.  However, all of these also checked another box (two were trans, three were non-trans significant others, and one was a non-trans friend).

Ninety-three (93) of the respondents gave their age.  A third (38%) were aged 35-44, and nearly another third (30%) were aged 25-34.  Seventeen percent (17%) of our respondents were aged 45-54, and 13% were aged 19-24.  We had two respondents under age 18 and none age 55 and older.

Of the 85 respondents who answered where they lived, 52% were in urban environments, 45% were in the suburbs, and 3% lived in rural areas.

Many people gave multiple answers when we asked about economic backgrounds and current statuses; therefore, we had 126 answers to this question.  “Middle class” or “upper middle class” was marked by 44%.  Working class was selected by 19%, student by 13%, disabled by 11%, lower class by 10%, and upper class by 2%.

Mental Health Services Used                                                           

Our survey respondents were almost universally mental health services consumers; only one said sie had used NO mental health services, and two others declined to respond to the question.  The vast majority – 88% -- had sought more than one type of service.

Individual therapy was the most common service type, with 95% of our respondents (N = 91) having used it.   The use of psychotropic medications was also popular; more than half – 51% -- had taken them.  Group therapy was commonly utilized; half our sample (N=48) had been involved in group therapy, and 51% had attended social support groups.  A third (N = 31) had belonged to a self-help group such as Alcoholics Anonymous, Narcotics Anonymous, and Overeaters Anonymous.  Another 15% (N=14) had used professional services for addiction.

“Alternative” methods of healing were frequently used.  Forty percent (N=38) had sought body work or energy work, and another 11% had used “other” types of mental health services such as acupuncture, biofeedback, cognitive skills building classes, family/marital therapy, meditation, occult practices, reiki, self-help books, and yoga.

One-fifth of our respondents (N = 20) had been hospitalized for mental health reasons.   This represents 23% of the trans respondents and 23% of the non-trans significant others.  No one who identified as non-trans and a friend or ally, on the other hand, had been hospitalized.  Only one of the 14 respondents aged 24 or younger had ever been hospitalized.

Reasons for Therapy                                                           

The vast majority of our respondents sought therapy for its own sake.  Of the 91 who saw a therapist, just seven (8%) saw a therapist only to obtain a letter for hormones and/or surgery.   Eighty-four (92%) wanted individual therapy, and thirty-two (35%) had sought couples or relationship counseling. 

Nearly half (47%) said they had seen a therapist at least in part to get a letter approving them to receive hormones, and 27% had sought a therapist’s help in obtaining a letter approving them for gender-related surgery.

I believe that the process used to screen trans people is an adversarial process.  I wasn’t there because I had issues to work through, but because I wanted access to hormones.  I found it a complete waste of time and money as opposed to the times that I sought therapy to resolve or address issues that were bothering me.

Other than asking whether people had sought therapy for a letter, we did not ask them to specify whether they saw a therapist for trans/SOFFA issues or something unrelated.  And as some respondents pointed out, making such distinctions can be difficult, anyway:

As a teen I was treated for depression and behavioral problems, but then not again until my mid 20s.  After getting on anti-depressants I was un-depressed for the first time in my life.  It was then that I was able to address a whole host of issues in my life, including my transsexuality.

The relationship issues that are already present can be really accentuated by a partner’s transition.

I have been in and out of therapy for 20 years and it was my gender therapist who was the first person to suggest that I get checked for ADD [attention deficit disorder].  As it turns out, I have an anxiety disorder and ADHD!  In the past, I’ve just been given antidepressants, which only helped slightly and temporarily.

I have noticed ever since I came out and admitted to myself that I am a trans guy I have felt better and happier.  So now I am starting to take care of my mental stuff better.

Started treatment for depression before recognizing trans identity.

Diagnoses                                                      

Only eight of our respondents said they had no mental health diagnoses or declined to answer the question.  Of the 88 respondents (92%) who had a mental health diagnosis, 73% (N = 65) had at least two.

Three-quarters (74%, N = 65) of the respondents had depression, and nearly as many – 67% -- had been given the diagnosis gender identity disorder.   Nearly half (44%) had been diagnosed with anxiety, and more than a third (37%) had post traumatic stress disorder (PTSD).  About a quarter (23%) had a sleep disorder.

The other diagnoses respondents had were: adjustment disorder (9%; N = 8); bipolar disorder or manic depressive (6%; N = 5); attention deficit disorder (with or without hyperactivity) (N = 4); grief or depression due to a death or loss (N = 4); and psychotic illness (N = 2).

Of the 24 respondents with only one diagnosis, eight were non-trans SOFFAs.  Trans respondents were therefore significantly more likely to have multiple diagnoses; only about 21% of the trans respondents had just one.  The most common sole diagnoses were gender identity disorder and depression (both with 9% of all respondents). 

SOFFA Therapy About Trans Issues

About a quarter of non-trans partners (N = 3) had received professional help to deal with trans issues; two others had considered seeking such help.  The majority, however (61%), had not considered it.  One of the non-trans SOs had sought help for hir own gender issues as well as help in dealing with hir partner’s transness.

In contrast, none of the four non-trans, non-partner friends and allies had sought or considered getting professional help in dealing with trans issues.

Psychotropic Drug Use                                                        

Of the 89 persons who answered a question about psychotropic drug use, a third  (35%; N = 57) were currently using such drugs and twenty-six (29%) had taken them in the past. 

There was a significant difference in psychotropic drug use among trans and non-trans respondents: nearly half of non-trans SOFFAs had never taken psychotropic drugs (47%; N = 8), compared to only 27% (N = 24) of the trans respondents.

The Practical Impact of Mental Illness

Our question about the impact of mental illness was poorly worded.  (“If you have a mental health condition, how much has it interfered with your daily function?”)   The question did not clearly distinguish between current difficulties and past difficulties, and some respondents designed their own new categories to make those distinctions.  Because others may have used the existing categories to reflect past but not current issues, the numbers associated with these answers should be interpreted with more than the typical level of caution.

Fifteen respondents did not answer the impact question, six added comments indicating their difficulties were only in the past, and 15 said the category was not applicable.  That leaves 66 who may have a current mental health condition.  Of these, about a quarter each said their condition interferes with their daily function “some.” Only two said their condition interfered with their daily functioning “not at all.”   Eighteen percent (N = 12) said it interfered “a little.”  An additional 4% (N = 3) said their condition varied, was sometimes debilitating, or varied between being debilitating and affecting their daily function a fair amount.

Mental Illness Attributed to Being Trans+/SOFFA

The majority of respondents felt their mental health issues were due at least in part to being trans and/or SOFFA; only 18 (20%) said their trans/SOFFA identity was “not at all related” to their diagnosis, and 14 others (15%) said the question wasn’t applicable. 

Four respondents (4%) said their mental health issues were 100% (or “totally”) related to being trans/SOFFA. 

Since transitioning I have had no mental health problems.  They were largely the result of denial and fear about being acceptable in the world as the person I am.

My struggles with depression and mental health have been directly related to my queer status and to body image issues generated by living in a culture that pathologizes any body that is “deviant” – i.e., anything other than thin, white, straight, conventionally attractive, and gender normative.  Incidentally, queer communities can exacerbate this as much as the straight/mainstream world.  It’s surprising that this survey does not address this at all.

The [trans] experience is a very difficult one and it takes an enormous amount of energy to keep safeguarded.  There is much sadness and frustration with no release for extended periods of time.  Keeping the secret is definitely detrimental to one’s health.  My wife knows about my Trans issues and it has practically destroyed our relationship, I can’t even imagine what it would do to what’s left of my life.  Thank God I have no children.

About a quarter of the respondents (23%, N = 21) said there was a “significant” correlation between their mental health and being trans+/SOFFA; the same number said there was “a little” correlation.  Thirteen respondents said there was “a fair amount” of correlation.

My mood disorder is inherited, it runs in my family and my son has a similar condition.  I was not diagnosed until a severe breakdown in my mid-30s but I am certain that without the co-existing gender dysphoria I never would have had that serious a breakdown or the full blown form of the disorder I now have.

Much of the daily abuse I’ve received in my life has come from how people have perceived me – making them uncomfortable with me.  I’ve survived attempted rapes, been beaten up, and stalked and fetishized for being differently gendered.

On the psychological axis, I think having buried so many issues, the deepest-buried being my desire to be male, that of course I would get depressed recurrently until I had admitted them to myself and others.

Social stigma and expectations about gender, genitalia, and passing have impacted my mental health in negative ways.

It has occurred to me that my reluctance to make/keep/contact/trust friends is partly due to being closeted for so long about being transsexual.

Of course, the relationship between being trans and having a mental illness can be complex, as one person pointed out:

[S]ome of us get so caught up in feeling like something’s wrong with us, but we’re unable to verbalize it yet.  So when a professional tells us we might be this or we might be that, we grab it.  “Hey!  So THAT’S what’s wrong.”  It makes us feel better to KNOW something finally.  Problem is … most of the time it’s just a side effect of the main issue that hardly ever gets delved into without a fight.

The majority of non-trans partners (but not friends and allies) said that being partnered with a trans person was at least a little related to their mental health issues.  Although 38% (N = 5) said they weren’t related at all and one said the question wasn’t applicable to them, 46% (N = 6) said they were related “a little” and one said they were related “a significant amount.”

Letter Requests Denied Due to Mental Illness

One of the primary fears of people who have a mental illness and seek medical assistance with a gender transition is that mental health gatekeepers will withhold their hormone and/or surgery approval letter/s because of the mental illness.  Our survey showed that while this fear is founded, 91% of the trans respondents (N = 80) said they had never been denied access to hormones or surgery due to a mental health condition.

Seven of the respondents HAD been denied access due to their mental health diagnosis.  Three were turned down seemingly out of the provider’s unwillingness to accept the legitimacy of transsexualism, or because the provider had a view of transsexualism that was incompatible with the person’s reality:

[The reason given was] that I was crazy and not TS; that there is no such thing as TSism.

Endo[crinologist] in my home area refused to see me for hormone therapy.  While she never knew anything about me and my situation specifically, her stated attitude towards TG people was, “That is a problem population” and I was specifically told, “she no longer sees patients with your kind of endocrine problem.”  Again, she never saw me to assess my endocrine problem in the first place!  So, my reading is that she sees all TG people as having a mental health condition that she doesn’t want to deal with.

Back when I first explored transition (age 21) the psychiatrist tested me and because in his opinion I would be gay after transition, he wouldn’t take me into his program.  His view was that transition should be a cure for homosexuality.  This was when homosexuality was still considered an illness.

One was turned down because professionals believed the person’s desire to transition was related to having been abused:  They thought I was only “GID” because I had been sexually abused as a kid.

The other three were given a variety of reasons.

Well, just today the therapist I have seen for the past 2-1/2 years stated she has too many reservations about my mental illnesses to give me a hormone letter.  I have been taking T[testosterone] without a script for 3-1/2 years.  She stated that there were too many “other” factors, like my husband is also FTM (she thinks I am copying him), my abuse history, the fact that I am unable to hold a job, to give me the letter.  She said it wasn’t personal and that she has to protect her license.  Oh…another reason for not giving me a letter was I didn’t bind.  I am a size H cup with Chronic Obstructive Pulmonary Disease.  I can’t bind.

He thought I was having too many problems, i.e., with health and mental health, and that unless I was well enough to work and stable he wouldn’t recommend hormones or surgery.  Also I don’t think he believed I was transsexual.  He thought I was [a] traumatized woman who was tired of being seen and harassed by men because I wasn’t masculine appearing before hormones.

 [The professional turned me down, saying] that I need to “know myself better” first.

Of the seven who were turned down, four sought a second opinion.  One who didn’t explained, No, [I] haven’t gotten a second opinion because [I am] “too young, too scared.”

Although we did not ask about this, two respondents volunteered that having a mental illness can also be problematic in the trans community:

I wish the trans community was more supportive of each other.  I know that I am barely tolerated because of having a mental illness.  Everything is supposed to be so smooth with transition and mine hasn’t been, so I get a lot of flack from other transmen.

I have minimal support within [the] TS community and [am] pretty isolated.

Experiences with Mental Health Professionals

We did not ask how satisfied people were with their therapy experiences, but many volunteered their opinions.  The negative stories ranged from outright abuse to ineffectiveness.

Two doctors have also done inappropriate sexual things to me in the context of examinations: one doctor laid on top of me and asked why I was a lesbian, and another put a hand up my shirt to see how large my bound breasts were.

I have had nothing but bad experiences with so called “gender specialists,” social workers, psychs, etc.  They either want to focus only on gender-specific stuff without looking at me as a whole person, or they think I’m butch just because of abuse in my past.  Most therapists have tried to box me into the “FTM” category because they can’t wrap their heads around the idea of a Butch who doesn’t ID as a woman, a masculine female who passes as a man in the world but still identifies with their femaleness, etc.

I went to a day treatment program at [name withheld] from April 1996 to February 1997 and in April 1996 I had just started living as a woman.  They didn’t know me as a man, but my ID said “male” at the time and had my male name on it, so the therapists were trying to get me not to wear makeup.  And once, in front of a group of mentally ill patients at a therapy session, one of the therapists said, “you’re really a guy.”  …There was also a patient there who was very religious and refused to call me [by my female name] and “she” and it seemed like my music therapist was protecting her instead of educating her about trans issues, or even gay issues.

As a teen I saw a therapist after leaving an unhealthy relationship and was, in my opinion, carelessly overmedicated (and addicted) for six months until I became noncompliant and refused to take any more.

I have found it difficult to find a therapist with experience, expertise, or competence in both trans stuff and other issues.

On the other hand, some respondents were deeply grateful for the care they’d received.

My psychiatrist was the greatest.  I was referred to him after I admitted for the first time why I drink myself into oblivion, end up in detox facilities, and attempt suicide.  He had seen transgendered people before but I was his first “FTM”.  First he sorted out my depression/grief/anxiety/alcohol abuse issues by reassuring me he would help with my GID once I was stable enough to process everything clearly and make informed decisions…. I am forever grateful to my psychiatrist for helping me get to the point I am today.  I am living and working as a guy and am the happiest I have ever been.

I’ve been very lucky with the mental health services I have received since “coming out” as trans.  I mention this because it seems that most people have very much the opposite experience.

I get excellent care from the Veterans Administration (VA) Hospital.

Most providers of the nine different ones I have seen were either helpful or admitted they were not equipped to deal with gender.   Finding the ones who were capable was key to my improvement and successful transition.

Most of the mental health services I have received have been excellent and primarily from private psychotherapists; the majority of them have not been for my gender identity issues but for my childhood trauma issues.

PTSD from family/relationship trauma superseded GID for most of my life in terms of levels of distress.  But this is mostly worked through, and I am transitioned, so I am fine on both accounts.  Luckily I never had to fight with my care providers to see these two as separate issues.

Involuntary Mental Treatment

Ninety-four people answered the question, “have you ever involuntarily received mental health services?”  Of those, two-thirds (N = 62) had never been involuntarily treated, and four did not believe they had ever been involuntarily treated.  But 30%, or 28 respondents, had received involuntary treatment. 

I had to go [to an abusive outpatient clinic] so that I wouldn’t get kicked out of the homeless shelter that I was staying at.  As long as I was going there, I wouldn’t get kicked out of the shelter….it also got me into the [Department of Vocational Rehabilitation] so that I could receive job training.

Involuntary treatment can have many ramifications, as some of our respondents pointed out:

I became much worse when I was put in that hospital (as a teenager).  Because of that experience, I have not talked to my family in 16 years.  I also did not receive medical attention for my real problems for many years because I was afraid of being hospitalized or made to take meds.

At age 17 my mother found out that my boyfriend was born a woman, after reading a journal of mine which was delving into my inner conflicts regarding sexuality (previously lesbian).  A combination of my age, and his age (then 22), and her conservatism led her to believe I had been “converted, brainwashed”…something.  So she took me for a needs assessment at a local conservative suburban mental institution/chemical dependency rehab.  I believe she told them I had attempted suicide, because most of my treatment seemed to be centered around that.  I had never felt suicidal up until then.  When I turned 18, I left home as fast as I could.  I have no relationship with either of my parents.

The types of services respondents had had forced on them were therapy (68%, N = 19); hospitalization (43%, N = 12); medication (29%, N = 8); and electroshock therapy (7%, N = 2).  Five persons – 5% of our total sample – had had forced “treatment” to address their gender identity.

Yes, my fucked up parents put me in therapy from when I was a toddler for acting “gender wrong” (sic), or so I since found out.  They did everything possible to make me conform, I mean everything.  Six years ago I left home.  And I’m still in therapy to get over the so-called “therapy” I was subjected to by my parents and the medical establishment.  I was called pervert, evil, etc. and a servant of satan.  I was exorcised.  I was hit and worse.  My sister became a religious far right and choice evangelical fundamentalist because of me and then she had a mental breakdown at university, she tripped out and was institutionalized and medicated.  She in fact is the only one in the immediate family to be diagnosed as having a mental illness.  Now my parents are in therapy too because of my ts-ism and they say it’s all my fault….

Currently seeing a therapist as a condition of my mother’s continued financial support (college tuition), although I don’t believe I need therapy.  My therapist agrees, but is willing to help me deal with my mother.  [The therapist] is supportive of my transition.

Although the numbers are too small to draw conclusions from, involuntary treatment did differ some by age: both of the respondents under 18 had been involuntarily treated, and 39% of those 25-34 had had forced treatment.  The percentages of the other age groupings were all around a quarter.

Both of the minors were struggling.

They won’t let me get hormones until I’m 18, but then they have to ASK why I’m depressed.

I have had insomnia since the age of six.  I am now sixteen.  Nobody knows I am transsexual.  My father would be violently outraged if he knew.  I…cut myself up in secret.  I will not let myself be treated.  I have had schizophrenia experiences no one knows about.  I abuse my body to make myself stop menstruating and to hinder breast growth.  I cannot function in school and often do not go.  My friends make fun of me every day, as do enemies.  I cannot get help.  I cannot talk to anybody.  I cannot get hormones, and it is very hard and … [unclear] to cross-dress.  There are no support groups, online or real.  And there is nobody like me.  Everybody hates me and I am very unhappy.  I animate.  I draw comics about my transsexuality and nobody understands.  They get scared when I talk about sexuality.  I need help please.  I cannot give you my address because my parents may read a return letter if they suspect it.

[Editor’s note:  We attempted to contact this person to provide hir with free, online and in person support alternatives.]

Suicide Attempts

The vast majority of respondents had at least considered suicide:  47% (N = 44) had “considered” it, and 33% (N = 31) had attempted it.  Only 18 had not attempted or considered suicide, and three declined to answer the question.  One respondent cautioned that dividing those who had attempted from those who had “considered” it might lead to false assumptions:

To elaborate…I think about it all the time, I’ve wished I was dead since I was 5 or 6.  My suicide is years overdue, but I’ve been taking care of people and animals who rely on me.  I can’t leave til they’re safe or have died of natural causes.  I want my life to end soon, but I need to wait until my passing won’t harm anyone.  I’ve never attempted suicide even though my suicidal preoccupation is intense and nearly constant.  I hope this isn’t too much information, but I wanted to clarify that my answer of “no, but I’ve considered it” doesn’t imply that my suicidal thoughts are rare and fleeting intrusions into an otherwise satisfying life.  My daily life experience is deeply unhappy and painful.  I’ve learned to cope and survive, but it’s still not worth living.  I hope this isn’t too depressing to read.  It seemed important to tell the truth.

Of those who had attempted suicide, most made multiple attempts; only 29% (N = 9) had attempted only once.  The number of additional attempts went up to 75 and “lost count.”

The question of suicidal feelings was one of the few in which answers differed significantly based on whether the respondent was a trans person, a non-trans partner, or a non-trans friend or ally.  While only 16% (N  = 12) of trans persons had not considered suicide, 31% (N = 4) of non-trans partners had never been suicidal, and 50% (N = 2) of non-trans friends/allies had not considered suicide.

Age did not make a significant difference in suicide attempts.  With the exception of the under 18 respondents (where one of the two had attempted, resulting in a 50% rate), all of the other age ranges fell within 31-34%.  Note that this question did not ask when the suicide attempt(s) took place, and some respondents volunteered that their attempts took place when they were much younger.

The vast majority of those who had attempted suicide had a diagnosis of depression (with or without other diagnoses): 77% (N = 24).  Three of the attempters (10%) had a single diagnosis of GID.  Three of the attempters (10%) had diagnoses of GID and PTSD.  One person had not claimed any mental illness or GID diagnosis.

Mental Health and Hormones

Eighty-seven respondents answered the question, “If you have a long term mental health condition and are on any form of hormones (testosterone, estrogen, progesterone or other – for reasons of birth control, HRT after menopause, same/dominant hormone enhancements, or “cross-gender” hormones), have you noticed if the hormones have had any effect on your mental health condition(s)?”  Thirty-seven (42%) said the question was not applicable to them, and two said they were on hormones before the onset of their mental illness.

Therefore, 47 (54%) said they had a mental illness that might have been affected by hormone use.  Of these, the vast majority (70%, N = 33) felt that their mental health had improved when they started hormones.  Some of these transformations were dramatic.

Within 12 hours of my first testosterone shot, my depression was lifted like a black cloud.  Even now, when I’m late on my shots, I feel it seeping back in.  As long as I get my hormones, I’m fine and have no mental health issues.  So I don’t know if this counts as anything more than a hormone disorder.

I cannot begin to explain how much more functional I am in every way since beginning hormones.  It is incredible.  But I don’t expect it to “cure” my mood disorder, only make it very manageable.

Yes!!  Surprisingly to me, I feel that taking hormones has really helped me see whom I really am!  I always knew that I was different, but not till taking them did my outlook on “everything life” improve.  My complete outlook on how I am part of a human race feels “right – correct.”  As the other, I was never happy or never not confused as to my place in this world.  I feel right!

Others reported they developed a general sense of calmness and well-being once they started on hormones.

T[estosterone] seems to have settled my mind and my emotions to a comfortable level.

Depression runs in the family and waxes and wanes, but T[estosterone] has been very helpful and stabilizing.

The effects of T[estosterone] were immediately felt as a sense of calm and a certain peacefulness.

I feel a general sense of “better” and “good” since starting on T[estosterone].  I’ve had six shots now, and some kind of calm/peace has set in.  I don’t know if this is physical, mental, emotional or spiritual, but it feels good.

[A]ll of my friends reported that I have become more mellow since I started testosterone.

I am somewhat moody/depressed when not on testosterone, but it only affects my enthusiasm, not my functioning.

T[estosterone] adds a significant stabilizing factor and I am able to keep my psych meds (depakopte) at the lower end of the therapeutic range or just below.

I have improved steadily since starting HRT, 9 months ago.  I am beginning to enjoy a productive, fulfilling existence, for the first time in my life.

After beginning hormones and getting my transition underway, I went off anti-depressants and haven’t had what I considered any “serious” depression problems since (over two years).

A quarter of the respondents had noticed no change in their mental condition once they started hormones.  Two (4%) said using hormones worsened their mental condition. 

Anxiety bouts that I have had post-T[testosterone] have been pretty much the same as pre-T[testosterone].  I have checked out if there is a relationship and I don’t think there is.  I had been hoping T[testosterone] would help alleviate my anxiety, but that hasn’t happened either.

One person said he had experienced both improvement and a worsening after beginning hormones. 

Since starting on testosterone, my depression got better overall, but when I had another episode – relapse? – it was worse than any of my previous episodes.  I cannot say if this was due to the testosterone or just the documented pattern of later episodes being more severe than earlier episodes for most people…. The parts of my depression that were related to PMS went away entirely, which is not surprising.

All three of those who said their conditions had worsened with hormone use had multiple diagnoses. 

Two respondents volunteered that they had hoped hormones, surgery, and/or transitioning would help with their social discomfort: 

My depression has eased since starting on testosterone, but my willingness to be social has not increased as I thought it would.  Perhaps after I’ve had top surgery.  Perhaps after I have decent facial hair.  Perhaps I’m just an introvert and will never feel comfortable around very many people.

I’ve never been diagnosed with any kind of social phobia but I am painfully introverted and people often say I come across as retarded or autistic.  I am intelligent, University educated, capable etc. but just find it near impossible to open my mouth most of the time.  I am curious if going on hormones and passing as male will change that.  Makes sense that if the world saw me right then I’d be more able/interested in interacting with this world.

Mental Health Techniques                                         

With five exceptions, all respondents had at least one technique they used to maintain or improve their mental health, and most used multiple tools.  In order of their use, the tools respondents used were: exercise (77%); therapy (72%); journaling (58%); vitamins or supplements (52%); meditation (52%); medication (45%); body work (36%); prayer (36%); diet (36%); herbal supplements (34%); energy work (26%) and crystals or rocks (15%).

Thirty respondents wrote in other techniques.  Talking to friends and family was mentioned most often (N = 8). 

Having friends to talk to has always been more effective than therapy. 

Other volunteered techniques were art, music and sex (used by four respondents each); reading and rituals (three each); and activism/community-building, dancing, yoga, going out, cognitive restructuring, and optimism (two each).  Other mentioned techniques included traveling, having fun, making revolution, writing for publication, driving, Bach remedies, burning incense, using marijuana, being in water, regular sleeping patterns, magick, looking at pictures of self and other transmen, and isolation.  One found solace in Buddhism:  [It] has a long history of understanding and addressing mental health.

Some people said transitioning or surgery was crucial to their mental health: 

My mental health is good since surgery and I believe I lead a normal hetero life.

It has taken a REALLY long time, but working on my depression, relationships with people, and actually transitioning has gotten me to a mental place that I really feel that I am doing very well.

Insurance Coverage

A significant influence on how accessible are mental health services is whether one has health insurance, and specifically health insurance that covers mental health services.  About 45% (N = 43) of the survey respondents had mental health coverage.   Twenty-two percent (N = 21) had no health insurance at all.  Ten had health insurance that excludes mental health, and eleven respondents didn’t know if they had insurance that covered mental health care.

Most of those with mental health coverage had some limitation on that coverage: more than half (N = 25) have a cap on the number of visits or sessions they can have, and nearly half (N = 21) must choose a therapist from a limited list of providers.  However, nine could see any therapist they wanted, and 11 had no cap on the number of sessions their insurance would cover.

Related to insurance coverage is poverty, which is in turn related to other issues:

[I] cannot afford chest surgery and have attempted and failed to remove breasts 2X.

It has only been in the last couple of years that I have been able to get help from competent counselors (for sexuality and identity issues) and that I have had ANY access to healthcare.  Poverty has been a big problem.

Conclusions

The trans+/SOFFA community has a complex, ongoing relationship with mental health issues and the mental health service community.  Although it is frequently pointed out that one cannot be "officially" trans without at least some contact with the mental health system, our survey found that many members of our community seek mental health services because of conditions outside of their gender identity.  

These other mental health conditions may or may not be linked to gender identity (and, in particular, to transphobia against those whose gender identity violates the strict binary norms), although the majority of respondents felt that for them, there was a link.   For some people, resolving their gender identity -- often by transitioning -- helped lessen or end their other mental health concerns.  For many others, hormone use by itself seemed to have a very welcome side effect of improving their non-GID mental health conditions.   This finding, in particular, deserves far more exploration and rigorous research.

It is no surprise that the trans+/SOFFA community's relationship with mental health providers is complex and ambivalent, because of mental health providers' unique role of gatekeeper to the medical and, sometimes, social means through which trans+ people communicate their identity.  What is, perhaps, surprising, is how many of our respondents have positive stories to tell about how their therapists respectfully and competently helped them resolve even very complicated clusters of conditions and issues.   Unfortunately, a few have also found the opposite: mental health professionals who used co-existing diagnoses or even just their own ignorance and prejudice to create even more trauma and pain in the lives of their trans+/SOFFA clients.

One finding that we particularly need to pay attention to is how much impact non-GID mental health conditions have on our community and its members.  Two-thirds of our respondents have an ongoing mental health condition, and three quarters of these say their condition affects their daily functioning at least "some," with a quarter characterizing their condition as "debilitating."  Perhaps more so even than the incidence of suicidal feelings in our community -- 80% of the respondents had at least considered suicide -- the implications of this level of daily functioning impairment need to be discussed far more deeply.   How can we organize our community to provide better supports for those with mental health issues?  Are there organizing implications of these findings -- i.e., do we need to think about how we go about planning conferences, support groups, etc. to better accommodate the levels of mental health “disabilities” of our members?   Do we need to do a better job of talking about the overlaps between GID and non-GID mental health conditions when we train and/or screen therapists?  What else should these findings be making us think about?

Send your ideas to editor@forge-forward.org.