Volume 6, Number 4, 2002

Transgender Identity Affirmation and Mental Health

Larry Nuttbrock, Ph.D.
Project Director
National Development and Research Institutes (NDRI)
71 West 23rd Street, 8th Floor
New York, NY 10010

Andrew Rosenblum, Ph.D.
National Development and Research Institutes (NDRI)
71 West 23rd Street, 8th Floor
New York, NY 10010

Rosalyne Blumenstein, MSW
725 DeLongpre Avenue
Los Angeles, CA 90046


This paper formulates a social psychological perspective for the mental health functioning of transgender persons. Affective symptomatology in this population is viewed as significantly affected by the extent to which transgender identity is successfully incorporated in social roles and relationships. The extent to which transgender identity is disclosed to others so as to be recognized by them, performed in the presence of others, responded to by others, and supported by others, is summarized in terms of a broad construct – transgender identity affirmation. Affirmation of identity, following social psychological identity theory, is posited as crucial for emotional well-being. Some support for this perspective was observed in a preliminary study of 43 trans women sex workers in New York City. Additional research along these lines is needed to better understand the complex association between transgender identification and mental health functioning.


Keywords: trans women, self conception, social roles, depressive symptoms, identity theory




Early reports of transgender persons as "miserable souls" who "plough their lonely and unhappy rum path through life" (Hoenig, 1985) were followed by a number of studies in which these individuals were characterized as "generally well adjusted" (Bentler, 1970; Bullough et al., 1983; Feinbloom, 1976; Cole et al., 1997). In recent years, a number of well-designed studies of this population have observed high levels of depressive symptomatology, affective disorder, and suicidality. Clements-Nolle et al. (2001), for example, in their community-based sample of transgender persons in San Francisco, found that 62% of the trans women were depressed (using an established cut-score on the CES-D). Several investigators have observed comparatively high levels of anxiety and suicidal ideation in this population (Pauly, 1993)

As the above literature suggests, there is continuing disagreement about whether or not transgender persons, as a group, are significantly more mentally impaired than the general population. Most investigators would probably agree, however, that a significant segment of this population suffers from some degree of emotional distress (Jones and Hill, 2002).



Explanations for Mental Health Problems among Transgender Persons

A variety of explanations have been suggested for the etiology of emotional difficulties in this population.


Early development in the context of family relationships

One view sees the mental health problems of transgender persons, and perhaps this condition itself, as bound up with early family difficulties and trauma. An absent or abusive father, or an overindulgent or abusive mother, and other aspects of family conflict during early development, may impede identification with a same-gender parenting figure (Stoller, 1968). From a somewhat different perspective (Kohut, 1971) the "mirroring" of the self in relationship to significant others may be distorted among some transgender persons. This may be manifested as narcissistic pathology or some other form of personality disorder (Hartmann et al., 1997). Others have viewed transgender identification of children as a maladaptive defense mechanism in the context of a threatening environment (Ovesey and Person, 1976; Devor, 1994).


Negative body image

Another view traces emotional distress among transgender persons, more specifically, to a negative body image. "A sense of awkwardness or discomfort about one’s anatomical sex is often linked to negative affect associated with these ideas" (Steiner et al. 1985). Transgender persons have long been described as "fundamentally disliking" their biological sexual characteristics (Hoenig, 1985). According to Benjamin (1966), transgender persons exhibit intensely negative attitudes toward their genitalia, in particular. For trans women, the penis supposedly becomes an "organ of hate and disgust" (Benjamin, 1966). From this perspective, negative attitudes toward one’s self (one dimension of depression) are epiphenomenal to underlying negative attitudes toward one’s body.


Sexual minority stress

Others have pointed to perceptions of stigma and experiences with discrimination associated with "gender variant living in an often hostile environment" (Cole et al., 2000). Because they transgress fundamental norms of the binary gender system, transgender persons are thought to be at the "low end of the hierarchy of acceptability" in American society (Herek, 1987). Recent studies indicate that these individuals experience stigma and discrimination in seeking housing, employment, and social services, and are not infrequently verbally and physically abused. There is some evidence that these perceptions and experiences take a toll on mental health functioning in this population (Jones and Hill, 2002).


Transgender identity and social relationships

But in addition to the above factors, most investigators would probably agree that the mental state (and perhaps mental health) of transgender persons is affected by the extent to which transgender identity is incorporated in social relationships and supported (or not supported) by relationship partners. The interpersonal relationships of transgender persons have been described in a number of qualitative and small-scale studies.

Informing a long-term sexual partner (or spouse) about one’s trans identity is often associated with interpersonal turmoil, especially if the relationship was formed on the basis of a non-transgender identity (Brown, 1998). Some relationships with existing sexual partners are re-negotiated in which a transgender identity is accepted and reciprocated (Prince, 1976).

Informing parents about transgender identity is described as critically important (Parker and Barr, 1984). The failure of parents to acknowledge the legitimacy of this identity is viewed as an obstacle to achieving a sense of self-acceptance among transgender persons (Bolin, 1988; Sapora and Brzek, 1983). Identity-affirming relationships with parents, when they occur, are described as a type of "symbolic rebirth." Among trans woman, parents were "the source of their birth and nurturance as males and symbolically can be the source of their rebirth and nurturance as females" (Bolin, 1988).

Some siblings, caught between their beliefs about proper gender roles, and their personal loyalties to a brother or sister, have been described as dismissive and hostile to transgender persons (Sapora and Brzek, 1983). When it occurs, acceptance by siblings is described as vitally important; it may represent a type of "retroactive credibility" for a trans identity (Bolin, 1988).

Changing genders in the context of relationships with children may be charged with emotion and confusion. Despite these difficulties, relationships of transgender persons with their children have been formed in which finding novel ways of dealing with gender-variant living are a source of pride and distinction (Boszormenyi-Nagy and Spark, 1973).

In the process of transitioning, transgender persons typically sift through their friendship network, largely avoiding those individuals anticipated to be critical toward their newly celebrated core gender. Some friendships may be re-established, based on one’s new gender, and new friendships may be developed. Whether old or new, "celebrations of identity" with friends provide much-needed emotional support, and generally legitimate a gender-variant lifestyle (Blumenstein, 1998).

Changing one’s gender presentation in the workplace is a unique challenge. "Turning over" (changing genders) in the context of existing employment is not infrequently associated with strained relationships with co-workers and supervisors, which frequently results in loss of employment (Bolin, 1988). In sum, the social relationships of transgender persons appear to be a complex array of both negative and positive experiences, in the context of different relationships, which frequently change over time.



A Conceptual Formulation for Transgender Identity and Social Relationships

The complex array of experiences in social relationships, and their affects on mental health, can be conceptually understood in terms of four general processes:

  1. Identity awareness: "Keeping the secret" about one’s transgender identity from others may, in itself, contribute to emotional distress (Cole et al. 2000). On the other hand, disclosing emotionally significant aspects of one’s self concept to others has long been suggested as contributing to mental health (Jourard, 1971).
  2. Identity performance: Even if a transgender identity is revealed to others, a failure to act upon it in the context of the relationship may negatively affect mental health. Behavioral expressions of transgender identity, such as "cross dressing," may produce a sense of well-being. This was nicely demonstrated in a study by Blanchard and Steiner (1985). In a sample of 55 trans women, a scale of "social reorientation," based on reported cross-dressing and role-playing in four role contexts, was strongly associated with fewer depressive symptoms.
  3. Identity congruence: Even if others are aware of transgender identity (identity awareness), and this identity is acted upon in the context of the relationship (identity performance), a failure of relationship partners to respond in terms of this identity may be disconcerting. A reciprocation of transgender identity (identity congruence) may contribute to mental health.
  4. Identity support: If relationship partners respond in terms of a transgender identity (identity congruence) the content of this identity is critical. It may vary from ridicule and devaluation (identity rejection) to acceptance, positive reinforcement, and behavioral reciprocation (identity support). The type of behavioral response (rejection versus support) is seen as critically significant for the well being of transgender persons (Boswell, 1998).



Theoretical Perspective

The associations between the four dimensions of transgender identity affirmation and mental health functioning can be understood in terms of identity control theory (Burke, 1980). The process of self-conception in relationship to others is viewed as a "homeostatic" system. A mismatch between self-conception and input from role performances (or non-performances) is registered as negative affect (a signal of system dysfunction) (Cast et al., 1999). A match between self-conception and role performances is registered as positive affect (Stets and Tsushima, 2001). The fit between how we see ourselves and perceptions of how we are seen by others, has historically been understood in terms of a "self-consistency" motive (Rosenberg, 1979; Higgins, 1999). The process of "identity support," (the fourth aspect of identity affirmation) is emphasized in the classic work of McCall and Simmons (1966).



A Preliminary Study

A study of female sex workers in New York City (Nuttbrock et al., 2003) included an over-sampling of trans women sex workers (n=43) for the purpose of describing this sub-population. The respondents were primarily non-white (33% Hispanic and 49% African American) with a mean age of 33 years and a mean education of 12 years. Substance use during the prior month were: alcohol = 70%; marijuana = 47%; crack cocaine = 30%; powder cocaine = 14%; benzodiazepines = 12%; other, less than 10%. The use of substances among these trans women sex workers should be seen, in part, as an attempt to cope with a challenging environment. Depressive symptoms were measured using a short (8-item) version of the CES-D (Radloff, 1977) validated by Melchoir et al. (1993). Using this scale, on which a score of 8 or higher is defined as a level of symptomatology consistent with a depressive disorder, an average score of 7.98 (sd=6.80 with a range of 0-23) was assessed in this sample.

About half of the respondents (51.2%) reported a current spouse or living partner. Almost all of these partners (96.2%) were described by the respondent as "completely" seeing their female attire as a "a natural part of who they are".1 Only a few of these partners (8.2%) were described by the respondent as "completely" critical of their female attire. No association was observed between an index of "identity support" constructed from these two items and depressive symptoms (which may reflect a lack of variation in the items).

The vast majority (79.1%) of the respondents reported one or more friends or acquaintances that were aware of their use of female clothing. Some (17.6%) were reported to be "somewhat" or "completely" critical of their female attire; 79.4% were viewed as "completely" respecting their use of female clothing; 85.3% were reported to "completely" see the respondent’s female attire as a "natural part of who they are". There was a negative and statistically significant association (r=-.26; p=. 05) between depressive symptoms and an index of friends’ support for transgender identity (representing the above items).

Forty-two (97.1%) of the respondents indicated that at least one family member (other than main sexual partner) was aware of their female attire. About half (55.9%) saw their family as "completely" respecting their use of female attire; 50.0% indicated that their family "completely" accepted this behavior as a "natural part of who they are as a person"; on the other hand, 26.5% indicated that their family criticized or made fun of their use of female attire either "somewhat" or "completely", and 35.3% indicated that they were "somewhat" or "completely" rejected by their family because of their use of female attire. Similar to friends’ support for transgender identity, there was a negative and statistically significant association (r=-.38; p=. 01) between depressive symptoms and an index of family support for transgender identity (representing the above items).



Summary and Conclusion

These data point to considerable variation in the extent to which a transgender identity is successfully incorporated in social roles and relationships. Those transgender persons with a current spouse or living partner reported high levels of identity support in the context of this relationship. This may reflect the selection of partners who share positive attitudes toward a trans life style. The respondents reported support for their transgender identity in most, but not all, of their relationships with friends and acquaintances. This may likewise reflect a process of social selection, where individuals with positive attitudes toward transgenderism are sought out socially. Compared to spouses/ living partners and friends/acquaintances, the respondents reported lower levels of identity support from non-conjugal family members. This may reflect that fact that these relationships are ascribed, not socially selected.

Transgender identity support (one dimension of identity affirmation) in the context of two types of social relationships (family member and friend/acquaintance) was significantly associated with depressive symptoms. The incorporation of a transgender identity in social roles and relationships, as theorized, appears to be one explanation for mental health functioning in this population. In contradistinction to the other explanations of mental health in this population cited above (issues associated with early development, negative body image, and sexual minority stress), which point to deficits or difficulties in the lives of these individuals, the affirmation of identity model advanced here points, more positively, to identity validation and personal empowerment as critical factors in mental health functioning. Additional research is needed to further elucidate the social psychological processes involved in the association between identity affirmation and mental health among transgender persons.




This work was supported by a grant from the Center for Substance Abuse Treatment (CSAT) (KD1 TI12049).




1. Trans women do not regard the wearing of female attire as "cross dressing".




Benjamin, H. (1966) The Transsexual Phenomenon. New York: Julian Press.

Bentler, R.M. and Prince, C. (1970) Psychiatric symptomatology in transvestites. Journal of Clinical Psychology, 26: 434–445.

Blanchard, R. and Steiner B. (1985) Gender reorientation, psychological adjustment, and involvement with female partners in female-to-male transsexuals. Archives of Sexual Behavior, 112: 149–157.

Blumenstein, R. (1998) The empowerment of a community. In D. Denny (Ed.), 427–430. Current Concepts in Transgender Identity, New York: Garland Press.

Bolin, A. (1988) In Search of Eve: Transsexual Rites of Passage. South Hadley: Bergin and Garvey.

Boswell, H. (1998) The transgender paradigm: Shift toward free expression. In D. Denny (Ed.), 55–61. Current Concepts in Transgender Identity, New York: Garland.

Boszormenyi-Nagy, I. and Spark, I. (1973) Invisible Loyalties. New York: Brunner/Mazel.

Brown, G.R. (1998) Women in the closet: Relationship with transgendered men. In D. Denny (Ed.), 353–371. Current Concepts in Transgender Identity, New York: Garland Press.

Bullough, V.L., Bullough, B., and Smith, R. (1983) A comparative study of male transvestites, male to female transsexuals, and male homosexuals. Journal of Sexual Research, 19: 238–257.

Burke, P. (1980) Identity processes and social stress. American Social Review, 56: 836–849.

Cast, A., Stets, J., and Burke, P. (1999) Does the self conform to the views of others. Social Psychology Quarterly, 62: 68–82.

Clements-Nolle, K., Marx, R., Guzman, R., and Katz, M. (2001) HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health interventions. American Journal of Public Health, 91: 915–921.

Cole, C., O’ Boyle, M., Emory, L., and Meyer, W. (1997) Comorbidity of gender dysphoria and other major psychiatric disorders. Archives of Sexual Behavior, 26: 13–16.

Cole, S., Denny, D., Eyler, A., and Samons, S. (2000) Issues in transgender. In L. Szuchman and F. Muscarella (Eds). 149–68. Psychological Perspectives on Human Sexuality, New York: John Wiley.

Devor, H. (1994) Transsexualism, dissociation, and child abuse: An initial discussion based on nonclinical data. Journal of Psychology and Human Sexuality, 6: 49–72.

Feinbloom D. (1976) Transvestities and Transsexuals. New York: Dell.

Hartmann, U., Becker, H., and Rueffer-Hess, C. (1997) Self and gender: Narcissistic pathology and personality factors in gender dysphoric patients. Preliminary results of a prospective study. International Journal of Transgenderism, 1,1: <http://www.symposion.com/ijt/ijtc0103.htm>. Accessed September 8th 2003

Herek, G. (1987) The context of anti-gay violence: Notes on cultural and psychological heterosexism. Journal of Interpersonal Violence, 5: 16–33.

Higgins, E. (1999) Self-descrepancy: A theory relating self and affect. In R.F. Baumeiser (Ed.), 150–181. The Self in Social Psychology. Philadelphia: Psychology Press.

Hoenig, J. (1985) Etiology of transsexualism. In Betty W. Steiner (Ed.), 32–73. Gender Dysphoria: Development, Research, and Management, New York: Plenum.

Jones, B. and Hill, M. (2002) Mental health issues in lesbian, gay, bisexual, and transgender communities. Review of Psychology, 21: 15–31.

Jourard, S. (1971) The Transparent Self. New York: D. Van Nostrand Company.

Kohut, H. (1971) The Analysis of the Self. New York: International University Press.

McCall, G. and Simmons C. (1966) Identities and Interactions. New York: Free Press.

Melchoir, L. Huba, G., Brown, V., and Reback, C. (1993) A short depression index for women. Education and Psychological Measurement, 53: 1117–1125.

Nuttbrock, L., Fong, C., Rosenblum, A., and Magura, S. (2003) Substance use/dependence and HIV seroprevalence of transgender sex workers in New York City. Abstract presented at the annual meeting of the College on Problems of Drug Dependence (CPDD) in Florida (June).

Ovesey, E. and Person, E. (1976) Transvestitism: A disorder of the self. International Journal of Psychoanalytic Psychotherapy, 5:221–235.

Parker, G. and Barr, R. (1984) Parental representations of transsexuals. Journal of Sexual Behavior, 2: 221–236.

Pauly, F. (1993) Gender identity disorders: Evaluation and treatment. Journal of Sex Education Therapy, 16: 2–24.

Prince, V. (1976) Understanding Cross Dressing. Los Angeles: Argyle Books.

Radloff, L. (1977) The CES-D scale: A self report depression scale for research in the general population. Applied Psychological Measurement, 1: 385–401.

Rosenberg, M. (1979) Conceiving the Self. New York: Basic Books.

Sapora, I. and Brzek, A. (1983) Parental and interpersonal relationships of transsexuals and masculine and feminine homosexual men. Journal of Homosexuality, 9: 75–85.

Steiner, B., Blanchard, R., and Zucker, K. (1985) Introduction In Betty W. Steiner (Ed.), 1–6. Gender Dysphoria: Development, Research, Management, New York: Plenum.

Stets, J. and Tsushima, T. (2001) Negative emotion and coping responses within identity control theory. Social Psychology Quarterly, 64: 283–295.

Stoller, R. (1975) Sex and Gender, Vol. II: The Transsexual Experiment. London: Hogarth Press.


Correspondence and requests for materials to: nuttbrock@ndri.org