Depression Among Transgender Older Adults: Differential Impact of Minority and General Stress

Background and Purpose: Depression is a major public health issue, affecting 6.2% to 8.9% of Americans aged 50 and older. Community-based research suggests that the incidence of depression may approach 50% among transgender older adults, but our understanding of mechanisms of risk related to depression in this marginalized group is limited. The minority stress model posits that in addition to general stressors typically experienced by most people, minority individuals also experience stressors unique to their marginalized status, which can result in mental health disparities. Minority stress research rarely accounts for both general and minority stress. The purpose of this study is to identify relationships between concealment of gender identity and internalized heterosexism, the most proximal of minority stressors, perceived general stress, and depression to identify the differential contribution of general and minority stress in transgender older adults mental health.

Methods: This study analyzes cross-sectional data from the The National Health, Aging and Sexuality Study: Caring and Aging with Pride Over Time project, the first federally-funded national study to examine the health and well-being of lesbian, gay, bisexual, and transgender adults (LGBT) aged 50 and older. Eleven agencies across the U.S. that provide services to LGBT older adults distributed surveys via their mailing lists. Of the 2,560 respondents aged 50 to 95-years old, 7% (n = 174) self-identified as transgender and are included in this study.  Structural equation modeling was used to test direct and indirect a priori theorized relationships and to account for measurement error in the relationships between the manifest variables depression, as assessed by the short-form of the Center for Epidemiological Studies Depression Scale (CESD), and perceived general stress, as assessed by the 4-item Perceived Stress Scale (PSS-4), and the latent variables internalized heterosexism and disclosure of gender identity as assessed by the Homosexual Stigma Subscale and Outness Inventory respectively, while controlling for age, income, and education.

Results: Transgender participants ranged in age from 50 to 86-years old (M = 60.97; SD = 7.96), 64% identified as female, and 82% as non-Hispanic white. About a third (32%) identified as lesbian or gay, 27% as bisexual, 19% as heterosexual, and 22% as something else. Close to two-thirds (62%) had four or more years of college, yet 53% had annual household incomes less than $35,000. Concealment of gender identity is inversely related to internalized heterosexism (b* = -.186, p = .020), but no other study variables. Internalized heterosexism is indirectly linked to depression through perceived general stress (b* = 3.11, p = .009). The total effects of perceived general stress (b* = 5.93, p < .001) and internalized heterosexism (b* = 5.01, p = .003) are significantly associated with depression.

Implications: Both internalized heterosexism and perceived general stress contribute significantly to depression among transgender older adults, with perceived general stress mediating 61% of the effect of internalized heterosexism on depression. Future studies of minority stress among transgender older adults should consider both general and minority stress processes to further our understanding of underlying pathways of risk that lead to depression.