Having one’s name and gender affirmed on IDs such as birth certificates, passports and driver’s licenses can be a crucial step in legal and social gender affirmation, according to Olivia Shumate, an outpatient therapist at Appalachian Counseling and Psychological Services.
“Stigma can be passive or active, but each leaves a mark on the identity. Communities that experience stigma are always at a higher risk for mental health disorders,” Shumate said. “It is amazing how much it can mean to someone to use the correct name and pronoun, to not question their expression and identity but to simply accept them as they see themselves.”
In a recent cross-sectional observational study published in “The Lancet Public Health Journal”, data shows a lower prevalence of serious psycho logical distress, suicidal ideation and suicide planning among transgender people who have gender-affirming identity documents when compared to those with none.
“In my professional experience, I have witnessed trans-identified clients repress or hide their gender identity which led to substance abuse, depression, anxiety and sadly, sometimes suicide. As an analytical psychotherapist, I have seen mental health issues form as a result of repressed or suppressed parts of the self,” said Kara Catrelle, an analytical psychotherapist specializing in sexuality and gender-related issues based in Asheville.
The study aims to prove how gender affirmation, defined as an interpersonal and social process of actualizing one’s gender identity, might improve mental health among transgender to be our authentic, whole self which includes acceptance and support for all expressions of gender and sexuality,” Catrelle said.
However, the procedure to change an ID’s gender marker can vary from difficult to impossible due to policies connected with the ID change pro cess. According to the study, most U.S. states require a court-ordered name change to change a name on any government-issued ID. Some states require medical letters or affidavits to validate reclassification requests, and they can even require surgeries regard less of individual needs or conditions.
“Any thoughtful policy maker would look at the facts and statistics of who is vulnerable to violence and create policy to protect them,” said Miriah Feehery, a licensed professional counselor based in Asheville.
Being told explicitly or implicitly that identifying as transgender means they do not belong, are unworthy, need to change who they are to be accepted, are unsafe or inferior can negatively impact transgender individuals, according to Feehery.
“Depression, anxiety, learning difficulties, addiction and physical illness are some of the many ways that transgender folks can suffer from the impacts of a society that doesn’t fully accept them,” Feehery said. “Systemic oppression can be equated to living in a war zone. Sometimes the fear might break through the numbness and come out as anger, panic attacks, despair, depression or even mobilization to get out of the situation or change it.”
Researchers hypothesized how hav ing an ID that reflects one’s preferred name and gender marker could be associated with reduced psychological distress and suicide risk, including ideation, planning and attempts. The study observes how among trans youth, reduced depression, suicidal ideation and suicidal behavior associate with chosen name use.
“Many young people already know their gender identity. They are seek ing for cues of safety, validation and acceptance, though, before expressing it outwardly. When they receive only positive reinforcement for their gender assigned at birth, and possible scrutiny, correction and/or shaming for expressing themselves outside of that box, their true gender feelings could get repressed into the unconscious psyche,” Feehery said. “It’s also important to name that gender identity can change over the lifespan, just like sexuality can change.”
As one of the first studies in the U.S. to quantitatively examine the relationship between gender-affirming identity documents and mental health among transgender adults, the results show connections between having some or all gender-affirming IDs and better mental health among the participants.
“On a large scale, trans people must learn to live with and navigate the fear of societal exclusion that challenges their everyday lives. We learn to quickly assess people, environments and situations so we can attempt to protect ourselves. Living under this real and perceived threat eventually takes a toll, which is reflected in our mental health outcomes,” said Michael Hoben, board of directors member at Blue Ridge retention coordinator for WNC Community Health Services.
Among those whose IDs did not reflect the gender they identify with, a third experienced refusal of services harassment, violence or all three. Identity documents are often required to obtain important resources such as health care, housing, education and employment, according to the study.
“Like most marginalized populations, transgender people are subject to a range of overt and subvert forms of discrimination and inequalities that drive inequities that continue to op press gender non-conforming individuals – from education to healthcare to employment,” Hoben said.
The study acknowledges how identifying documents are also required for immigration, travel, citizenship verification, security clearances, social service applications and other major structural access points, as well as in daily activities such as socializing, purchasing items and engaging in recreational activities.
“I once went to Europe and planned on meeting a trans friend when I got there for a few days of sightseeing together. As we were making plans to meet up, I became more and more aware of the fact that he was worried about international travel. Apparently, there are certain countries that one must avoid if you are trans, as the customs and airline employees have a reputation for antagonizing and detaining folks in the trans community,” said, Iva Veazey a certified sexologist based in Asheville. “Of course, now, we are all subject ed to having our entire body scanned before boarding a plane. When a trans person doesn’t have the genitalia that an airline employee might expect to see on an average cis person scan, they tend to make the trans persons check points very challenging and often frightening.”
According to the report, psycho logical distress was measured with the Kessler 6 scale, which includes six items that assess the frequency of symptoms of non-specific psychological distress in the past 30 days. An analytic sample containing 22,286 participants living full-time or part time in a gender different from what they were assigned at birth was used for the study. Lower unadjusted levels of psychological distress on the Kessler 6 scale were reported by trans adults with all or some gender-affirming IDs, when compared to those with non-affirming IDs.
“When we do not feel accepted by our community it has a severe impact on how we interact with this community. People may start to feel fear about going out because others may not accept them, may avoid certain areas where they have fewer allies or feel hatred toward themselves by internalizing,” Shumate said.
The study finds most trans people living in their felt gender did not have fully gender-affirming IDs, with only 10.7 percent indicating that all of their IDs reflected both their preferred name and gender marker. According to the report, reasons for not changing their gender marker includes a lack of suitable gender options beyond male or female, cost and supposed ineligibility.
“Our paperwork allows for individuals to check ‘other’ for gender and to be identified by their preferred name,” Shumate said. “For insurance reasons, legal name has to also be present on paperwork, but the individual is still referred to by their preferred name.”
The study’s results further emphasize how legal gender affirmation proves to be a structural determinant of health for trans people, who already face inequities in health and access to health care. Based on a clear societal importance, identifying documents can be considered a fundamental element of health for transgender people. “The LGBTQ+ community is already at a higher risk for suicide and violence against them, which is mostly due to the stigma of others against them. They need safe places, like therapy, advocate centers and to be able to access medical care. This is what builds people’s resilience. Knowing that they are not alone and have places where they can safely be themselves,” Shumate said.