Gender Identity-Based Violence, Depression, and Anxiety in Transgender Women: The Role of Psychological Self-Appraisal

Background: Trans women experience high rates of depression and anxiety. Lifetime prevalence of depression among trans women may be as high as 63%. Multiple types and events of violence and discrimination (polyvictimization) are also common throughout trans' lives, which is correlated with negative mental health outcomes. Psychological self-appraisals (PSAs), or the degree to which one is satisfied with themselves, may mediate the relationship between polyvictimization, and depression and anxiety. Using a model of minority stress as guide, this study examines associations between polyvictimization, PSAs, and depression and anxiety among a racially diverse sample. Methods: 233 transgender women were recruited using respondent-driven sampling (RDS). RDS began with focus groups, leading to the selection of 12 individuals as starting seeds. These seed individuals were each asked to recruit three others, who in turn were asked to recruit three additional individuals. RDS was completed when stability was achieved on key variables: HIV status, race/ethnicity, income and age. Eligibility criteria included self-identification as male-to-female, age 18 years or older, and current residence in the city of San Francisco. A survey measuring the number of gender identity-based victimization experiences encountered, the degree of one’s negative PSAs, and history of clinical depression and anxiety diagnoses was administered using a handheld computer. Logistic regression, linear regression, and a bootstrapping process were used to assess the direct and indirect associations between polyvictimization, PSAs, and mental health outcomes. Results: Sample interviews occurred over a 21-week period. 57% (n=134) of the sample self-reported a diagnosis of depression and 42.1% (n=98) reported a diagnosis of anxiety. 84.1% (n=196) reported verbal abuse and 63.5% (n=148) reported physical abuse or harassment because of their gender identity or presentation. The mean number of victimization experiences reported by the sample was 2.7 experiences (SD = 1.8) out of 6 types of experiences assessed. Over 20% (n=50) reported negative PSAs. For each additional victimization experience, the odds of reporting a depression diagnosis increased 1.25 times (b = .222, p =.007), while the odds for an anxiety diagnosis increased 1.22 times (b = .207, p = .01). Polyvictimization was also significantly associated with one’s degree of negative PSA (b = .149, t = 5.34, p = .000), and PSA was significantly associated with reported depression (b = .450, p = .026, OR = 1.56) and anxiety (b = .787, p = .000, OR = 2.19) diagnoses. Bootstrapping revealed significant indirect and total effects in the final models. 29.6% of the total effect of polyvictimization on depression diagnosis, and 53.8% of the total effect of polyvictimization on anxiety diagnosis were mediated by PSA. Conclusions: Practitioners may be able to assist clients in developing positive PSAs to prevent depression and anxiety among trans women. However, individual intervention is likely not a panacea for a social context of violence and discrimination. Continued attention to education, policy, and other social change approaches that that reduce minority stress placed on trans women are needed. Researchers should continue to explore the effect of minority stress and affirming social environments on PSAs and mental health outcomes.