Addressing social determinants of mental health in therapy: A thematic synthesis

Background

The importance of addressing social determinants of mental health in therapy is well-documented. However, there appears to be limited research on what this actually involves in practice and how best to prepare therapists to work with individuals experiencing adverse social determinants.

Aims

The aim of this review was to draw implications for practice and training from reviewing research on addressing social determinants of mental health in therapy.

Methodology

A qualitative systematic review of the research on addressing social determinants of mental health in therapy was conducted, extracting papers from eight databases: Cochrane Library, ASSIA, CINAHL Plus, PsycInfo, Psychoanalytic Electronic Publishing, Science Direct, Scopus and Web of Science. Out of 127 papers found, five met the eligibility criteria and were quality-assessed and analysed thematically.

Findings

The thematic synthesis generated three main themes: “the therapeutic relationship,” “adapting to client context” and “community as a resource,” with eight subthemes.

Conclusion

This thematic synthesis highlights the importance of the therapeutic relationship and adapting mental health support to client frame of reference and context to address social determinants of mental health in therapy. It emphasises community as a helpful resource for informing training and therapeutic interventions, as well as a significant resource for people experiencing adverse social determinants.     

Mental health practitioners' attitudes towards transgender people: A systematic review of the literature

Background: A systematic review was conducted to critically evaluate and synthesize literature investigating mental health practitioners' attitudes towards transgender people.

Objective: Three primary objectives were outlined; first, establish whether overall attitudes are positive or negative. Second, explore whether training, education or experience influences attitudes and finally, examine participant demographics in relation to attitude trends.

Method: A systematic electronic search was carried out in March 2017 using Medline, PsycINFO, PsycArticles, CINAHL, ASSIA, and Web of Science electronic databases. Manual citation and ancestral searches were conducted on identified papers. Qualitative, quantitative and mixed method studies were eligible for inclusion. A total of 13 papers of mixed quality were identified.

Results: Existing literature is limited to cross-sectional, quantitative data and fails to investigate differences between implicit and explicit attitudes. Small to moderate convenience samples reduce the generalizability of data. Overall attitudes were positive although negative attitudes were more frequent in male, Caucasian, heterosexual, religious, conservative mental health professionals.

Conclusions: Refined scales are needed to address the unique heterogeneity within transgender populations. Future research should focus on how attitudes impact care provided and employ longitudinal designs to explore the sustainability of targeted attitudinal training.     

Investigating the social integration and wellbeing of transgender individuals: A meta-synthesis

Introduction: There is growing literature about the experiences of social integration and wellbeing of transgender individuals. However, there has been no synthesis across this body of research. Accordingly, the aim of this review was to aggregate, interpret, and synthesize findings from qualitative studies pertaining to the social integration and wellbeing of transgender individuals.

Methods: This study synthesized findings from 18 qualitative and mixed method studies which had explored the social integration and wellbeing of transgender individuals, using Noblit and Hare's meta-ethnography method. The Critical Appraisal Skills Programme was also used to appraise the 18 included studies.

Results: Data from the included 18 individual studies ranged from moderate to strong in quality. Data analysis revealed five major themes which influenced transgender individuals' daily lives. These were gender transition and disclosing gender identity, health and self-isolation, living with stigma and discrimination: health care, leisure and work, the importance of relationships, and last, overcoming adversity: stories of what can work.

Conclusion: This meta-synthesis reinforces many preconceived notions about transgender individuals. These include being at high risk of social exclusion, experiencing discrimination and stigma across many social situations, and last, being at high risk of poor wellbeing. This study also found that there is further need for studies that investigate the self-isolation of transgender individuals as well as this group's relationship and experiences with health care professionals and providers.     

Relationship among gender-related stress,resilience factors,and mental health in a Midwestern U.S. transgender and gender-nonconforming population

Background: Transgender and gender-nonconforming individuals experience more discrimination than their cisgender peers, and this discrimination can be associated with poorer mental health. This study used the gender minority stress model as a framework to examine the relationship among gender-related stressors and resilience factors and mental health outcomes. The study particularly aimed to increase knowledge of the gender-nonconforming population.

Methods: A community sample of 83 individuals that identify as a gender different than the sex assigned to them at birth completed an online survey. Depression and anxiety were assessed using the Center for Epidemiological Studies Depression Scale (CES-D) and Beck Anxiety Inventory (BAI), respectively. The Gender Minority Stress and Resilience measure was used to assess distal and proximal stressors and resilience factors.

Results: The median CES-D and BAI scores were 16 and 13, respectively. Forty percent had a history of non-suicidal self-injury (NSSI), 75% had experienced suicidal ideation, and 45% had attempted suicide. Proximal stress was found to be a positive predictor of depressive symptoms. Resilience was a weak negative predictor of anxiety symptoms. Distal stress was a positive predictor of suicide attempts, and resilience factors and hormone use were marginal negative predictors of suicide attempt. Trans women were significantly less likely to have engaged in NSSI, but had a significantly higher proximal stress score than trans men and gender-nonconforming individuals.

Conclusion: Our study found high rates of mental health problems in the trans and gender-nonconforming sample. Our findings in part support the gender minority stress model, with gender-related stress predicting certain mental health problems and resilience being a negative predictor. Overall, gender-nonconforming individuals have had similar experiences and mental health findings as transgender individuals.     

Mental health and quality of life in non-binary transgender adults: a case control study

Abstract

Background: The social challenges that non-binary people experience, due in part to social intolerance and the lack of validation of non-binary gender identities, may affect the mental health and quality of life of this population. However, studies that have distinguished between non-binary and binary transgender identities are lacking.

Aim: To compare the mental health and quality of life of a community sample of non-binary transgender adults with controls (binary transgender people and cisgender people) matched on sex assigned at birth.

Method: A total of 526 participants were included. Ninety-seven were classified as non-binary and were compared with two control groups: 91 people classified as binary and 338 cisgender people. Only transgender people not on gender affirming hormone treatment or who had not undergone gender affirming surgery were included. Participants were invited to complete an online survey that included mental health and quality of life measures.

Results: Non-binary people reported significantly better mental health than binary transgender people, but worse than cisgender people. Overall, there were no significant differences in quality of life between non-binary and binary transgender participants assigned male at birth and transgender females, but non-binary assigned males at birth had better scores on the psychological and social domains of quality of life than transgender males. Quality of life was better across all domains in cisgender people than transgender groups.

Conclusion: There is an inequality with regard to mental health and quality of life between non-binary (and binary) transgender people and the cisgender population that needs to be addressed. The better mental health scores in non-binary people may reflect lower levels of body dissatisfaction among the non-binary population. Mental health problems and poor quality of life are likely to have social causes and hence legislative measures and broader government-led inclusive directives should be put in place to recognize and to validate non-binary identifying people.     

Internalized transphobia and mental health among transgender adults: A nationwide cross-sectional survey in South Korea

Abstract

Introduction: Transgender people are stigmatized in South Korea (hereafter Korea), where cultural expectations of a biologically-based, binary sex and gender system present fundamental challenges to those whose gender identity does not align with their birth-assigned sex. A growing international body of literature implicates gender minority stress as a key contributor to transgender mental health disparities, but little research has been conducted on this topic in Korea. As in other cultural settings, depression and suicidality are urgent public health concerns for transgender people in Korea, primarily for those who have not initiated gender affirming medical treatment (GAMT), such as cross-sex hormone therapy. In the current study, an international and interdisciplinary team of authors apply the lens of gender minority stress to elucidate the relationships between a key facet of gender minority stress, internalized transphobia (ITP), and outcomes of depressive symptoms and suicidality.

Methods: Based on a cross-sectional survey of 207 Korean transgender adults, the current study evaluates the relationships between ITP and depressive symptoms, suicidal ideation, and suicide attempts. ITP was measured with an eight-item, Korean-language questionnaire adapted from the Gender Minority Stress and Resilience Measure through a translation and back-translation process.

Results: Korean trans women and trans men mean (mean age?=?26.4) were included in the analysis, most of whom had at least one experience of any GAMT. The findings of this study show that Korean transgender adults face similar public health concerns such as high prevalence of depressive symptoms, suicidal ideation, and suicide attempts. As predicted, ITP was significantly related to depressive symptoms, suicidal ideation, and suicide attempts.

Conclusion: The authors suggest potential clinical, policy, and research applications, including institutional interventions, to address structural and cultural barriers to optimal mental health and GAMT as well as mental health interventions to reduce Korean transgender people’s internalized negative beliefs about their gender identity.     

Gender congruence and body satisfaction in nonbinary transgender people: A case control study

Abstract

Background: Binary transgender people access gender affirming medical interventions to alleviate gender incongruence and increase body satisfaction. Despite the increase in nonbinary transgender people, this population are less likely to access transgender health services compared to binary transgender people. No research has yet understood why by exploring levels of gender congruence and body satisfaction in nonbinary transgender people.

Objective: The aim of this study was to compare levels of gender congruence and body satisfaction in nonbinary transgender people to controls [binary transgender people and cisgender (nontrans) people].

Method: In total, 526 people from a community sample in the UK took part in the study (97 nonbinary, 91 binary, and 338 cisgender identifying people). Participants were asked to complete an online survey about gender congruence and body satisfaction.

Results: There were differences in gender congruence and body satisfaction between nonbinary and binary transgender people. On sex-specific parts of the body (i.e., chest, genitalia, and secondary sex characteristics), nonbinary transgender people reported significantly higher levels of gender and body satisfaction compared to binary transgender people. However, there was no difference in congruence and satisfaction with social gender role between the two transgender groups (nonbinary and binary). Cisgender people reported significantly higher levels of gender congruence and body satisfaction compared to transgender people (nonbinary and binary).

Conclusions: There are differences in gender congruence and body satisfaction between nonbinary and binary transgender people. Nonbinary individuals may be less likely to access transgender health services due to experiencing less gender incongruence and more body satisfaction compared to binary transgender people. Transgender health services need to be more inclusive of nonbinary transgender people and their support and treatment needs, which may differ from those who identify within the binary gender system.     

A comparison of health disparities among transgender adults in Colorado (USA) by race and income

Transgender individuals face heightened risks for discrimination, harassment, and violence that impact their psychosocial well-being and physical health. However, few studies have thoroughly examined the general physical and mental health of transgender adults or within-group health differences by race/ethnicity and income. To that end, after controlling for health insurance status, age, and engagement in exercise, this study asks: (a) Are transgender people of color more likely than White transgender individuals to experience poor health outcomes? and (b) Is lower annual household income among transgender adults associated with poorer health outcomes? The study analyzes secondary data from a survey of transgender adults (N = 417) in one state in the western United States using multiple linear regression and logistic regression models. Results showed that transgender people of color had significantly greater odds than their White counterparts of having arthritis/rheumatoid arthritis/gout/lupus/fibromyalgia, or asthma but lower odds of being told by a provider that they had depression. Having a lower income was significantly associated with worse general health as well as multiple indicators of poor physical and mental health, including depression, anxiety, and suicidal ideation. We discuss implications for health care delivery for transgender people and for future research.     

Transgender and anxiety: A comparative study between transgender people and the general population

Background: Anxiety disorders pose serious public health problems. The data available on anxiety disorders in the transgender population is limited by the small numbers, the lack of a matched controlled population and the selection of a nonhomogenous group of transgender people.

Aims: The aims of the study were (1) to determine anxiety symptomatology (based on the HADS) in a nontreated transgender population and to compare it to a general population sample matched by age and gender; (2) to investigate the predictive role of specific variables, including experienced gender, self-esteem, victimization, social support, interpersonal functioning, and cross-sex hormone use regarding levels of anxiety symptomatology; and (3) to investigate differences in anxiety symptomatology between transgender people on cross-sex hormone treatment and not on hormone treatment.

Methods: A total of 913 individuals who self-identified as transgender attending a transgender health service during a 3-year period agreed to participate. For the first aim of the study, 592 transgender people not on treatment were matched by age and gender, with 3,816 people from the general population. For the second and third aim, the whole transgender population was included.

Measurements: Sociodemographic variables and measures of depression and anxiety (HADS), self-esteem (RSE), victimization (ETS), social support (MSPSS), and interpersonal functioning (IIP-32).

Results: Compared with the general population transgender people had a nearly threefold increased risk of probable anxiety disorder (all p < .05). Low self-esteem and interpersonal functioning were found to be significant predictors of anxiety symptoms. Trans women on treatment with cross-sex hormones were found to have lower levels of anxiety disorder symptomatology.

Conclusions: Transgender people (particularly trans males) have higher levels of anxiety symptoms suggestive of possible anxiety disorders compared to the general population. The findings that self-esteem, interpersonal functioning, and hormone treatment are associated with lower levels of anxiety symptoms indicate the need for clinical interventions targeting self-esteem and interpersonal difficulties and highlight the importance of quick access to transgender health services.     

The buffering role of social support on the associations among discrimination,mental health,and suicidality in a transgender sample

Introduction: Per the minority stress framework, trans individuals often experience psychological distress given the unique stress engendered by gender identity–related discrimination. Prior research has identified social support as particularly important for psychological distress and has suggested that social support may moderate this relationship. The purpose of the current study was to explore the patterns of connections among discrimination, mental health, and suicidal ideation in trans individuals and whether social support moderates these relationships. Methods: Participants (N = 78) completed measures of these constructs as part of a national online survey. Results: A series of simultaneous multiple regressions found that harassment/rejection discrimination was a unique positive predictor of mental health symptoms and suicidal ideation, with depression positively predicting suicidal ideation. A mediational model indicated that the association between harassment/rejection discrimination and suicidal ideation was fully mediated by depression. Three moderated meditational models were run, and one yielded a significant interaction, such that discrimination predicted suicidal ideation most strongly when participants had low social support from a significant other in comparison to participants who had moderate or high support. Further, conditional direct effects identified that discrimination led to ideation only for individuals with low support from friends or a significant other but not for those with moderate or high support. Conclusions: Helping trans individuals cope with harassment and rejection, particularly by drawing on social support, may promote better mental health, which could help reduce suicidality in this population.     

Experiences with stigmatization among transgender individuals after transition: A qualitative study in the Netherlands

Abstract

Background: Transgender individuals belong to one of the most stigmatized groups in society. Although the social stigma of transgender individuals has been examined many times, post transition stigma experiences among transgender individuals have received limited research attention. The aim of this study was to examine experiences with stigmatization among Dutch transgender individuals after their transition.

Method: Ten trans women (age: M?=?58.50, SD?=?9.49) and 10 trans men (age: M?=?42.90, SD?=?13.62) participated in face-to-face semistructured interviews. Grounded theory was used to conceptualize and analyze the data. We examined the positive and negative reactions that transgender individuals experienced in the period after their transition. Furthermore, we explored differences between experiences of trans men and trans women. Finally, we examined differences between cisgender men and women regarding their reactions toward transgender individuals.

Results: Participants reported improved psychological well-being since transition. However, they still experienced different forms of stigmatization. Trans women appeared to experience stronger social stigma than trans men. Trans women also experienced lower social status after their transition. They mainly experienced negative responses from cisgender men. Participants emphasized the importance of social and peer support.

Conclusion: The current study findings demonstrate the presence of stigmatization after transition and argue for psychological aftercare. Social and peer support appeared to be important for coping with stigmatization, and improving the social network of transgender individuals is beneficial. Health providers and researchers are recommended to promote the development of constructive coping skills for transgender individuals with interventions especially targeting trans women.     

Provider quality and barriers to care for transgender people: An analysis of data from the Wisconsin transgender community health assessment

Background: Transgender people in the United States often lack access to high-quality health care.

Methods: A group of researchers and transgender people came together in a community-based participatory research process to survey transgender Wisconsinites about their health care experiences. A multiple regression analysis of survey data was used to evaluate the association between barriers to health care, gender identity, and quality of medical and mental health care provider.

Results: Seventy-seven respondents were included in this analysis. Transmasculine respondents were more likely than transfeminine respondents to report barriers to high-quality health care, but having a high-quality medical or mental health care provider was associated with reporting fewer barriers to care across the entire sample.

Discussion: This community-based study suggests that health care providers play a key role in facilitating access to care for transgender Wisconsinites in the USA.     

The longitudinal association between social status insecurity and relational aggression: Moderation effects of social cognition about relational aggression

Previous research has shown that adolescents’ insecurity about their social status is related to their use of relational aggression. However, little is known about how adolescents’ social cognition may moderate this association. Employing a mixed-method approach and a short-term longitudinal design, this study addresses this issue by examining the moderation effects of attribution and outcome expectancies regarding relational aggression on the associations between social status insecurity and relational aggression among 476 Chinese adolescents (238 girls). The main results showed that self-serving attributions and instrumental outcome expectancies strengthened the positive and longitudinal association between social status insecurity and self-reported relational aggression. The findings of this study enrich our knowledge about the social cognitive processes pertinent to peer status and relational aggression among adolescents.     

Exploring rates of transgender individuals and mental health concerns in an online sample

Background: Prevalence estimates of adults identifying as transgender are scarce, particularly in the United States. Method: The current study endeavored to estimate the prevalence of individuals identifying as transgender in a large online sample of adult U.S. residents (n = 6,727) and compare the prevalence of common mental health disorders (depression, anxiety, attention-deficit/hyperactivity disorder) and the age of onset for individuals identifying as men or women versus those identifying as transgender. Results: The prevalence estimate of individuals identifying as transgender was 0.8%. Individuals identifying as transgender were significantly more likely than individuals identifying as men or women to report having had a single diagnosis or co-occurring diagnoses for all three disorders examined. Additionally, transgender individuals were more likely than individuals identifying as men or women to receive a diagnosis of anxiety or depression at a younger age. Conclusion: Given the prevalence of transgender individuals and the associations with common mental health conditions, clinicians must be informed and competent to care for their clinical needs. This study introduces online crowdsourcing resources as a potentially fruitful option for reaching and researching gender diversity.     

Macrosocial determinants of social integration: Social class and area effect

Theory and research on social support have paid little attention to the existence of important macrosocial variables determining level and content of social relationships. This study examines variations in social integration as a function of social class and residential area characteristics. Results for 234 subjects living in high and low risk neighbourhoods indicated that differences between higher and lower social class groups follow different patterns in different residential areas. Also, same social class position appeared to have different significance as a function of residential area characteristics. The levels of three social integration measures—community integration and satisfaction, community association and participation, and contribution in community organizations—were significantly higher for lower class in low risk neighbourhoods than in high risk ones. However, significant differences were found in only one measure for higher social class groups, with higher levels of community association and participation in high risk neighbourhoods than in low risk ones. The discussion examines a ‘social impoverishment’ hypothesis for high risk environments, and proposes possible protective factors for higher status residents. Relations between formal and informal sources of support, and implications for social intervention strategies are also considered.     

Job insecurity and the benefits of work

The presented study combines conservation of resource theory with latent deprivation theory to explain the negative relationship between job insecurity and mental health. Specifically, we propose that people who face the threat of job insecure would perceive worse access to the benefits of work, which would explain the negative effect of job insecurity on mental health. In a two-wave study, employees rated their perceived job insecurity, their access to the benefits of work, and their mental health. Cross-sectional multiple mediation analysis at Time 1 (n = 295) and Time 2 (n = 236) showed that the negative relationship between job insecurity and mental health was partly due to a perceived lack of the benefits of work. Longitudinal results (n = 173) revealed that job insecurity was related to a decrease in financial benefits, which in turn predicted mental health. However, this effect was only visible if it was not controlled for prior levels of the benefits of work. The results are discussed with regards to conservation of resource theory and latent deprivation theory and the potential of this framework for explaining negative mental health effects of job insecurity.