The Lancet Public Health: Transgender, non-binary, and gender diverse people more likely to have a long-term mental health condition, first England-wide study suggests

(Press-News.org) Study of 1.5 million people over the age of 16 in England, including nearly 8,000 transgender people, finds a higher proportion of transgender adults report having a long-term mental health condition than cisgender adults. Additionally, those with a gender identity other than cisgender male or cisgender female were more likely to report their mental health needs were unmet at their last general practice appointment.       Authors call for the NHS to become more gender-inclusive, including by introducing better training for health-care professionals to improve their ability to meet the mental health needs of trans, non-binary, and gender diverse patients.  The risk of having a long-term mental health condition in England is roughly one in six for transgender men and women (16.4% and 15.9% respectively) and one in ten for cisgender men and women (8.8% and 12.0%), suggests the first nationally representative analysis published in The Lancet Public Health journal. The risk of reporting a mental health condition was even higher for some gender minority groups, reaching almost one in two (47.2%) for non-binary transgender individuals. 

Previous evidence suggests a higher risk of some mental health conditions, such as depression and anxiety, amongst transgender, non-binary, and gender diverse patients compared with patients with male or female cisgender identities. However, these findings are from small studies focused on specific groups, such as students or patients seeking gender affirming healthcare, which are not generalisable to the full population.   

Dr Luke Munford, Senior Lecturer in Health Economics, University of Manchester, says “Trans, non-binary and gender diverse people across England face widespread discrimination, leading to stressful social interactions and feelings of unacceptance, increasing the risk of poor mental health. Additionally, gender dysphoria – a sense of unease due to a mismatch between a person’s biological sex and their gender identity – may increase the risk of poor mental health amongst some trans, non-binary, and gender diverse people, especially when combined with very long waiting times for NHS gender identity clinics.” [1] 

The study combined data from the 2021 and 2022 waves of the English GP Patient Survey [2], which in 2021 introduced more answer choices to questions on gender identity. Survey respondents, all over the age of 16, could choose one of five responses for their gender (Female, Male, Non-binary, Prefer to self-describe, Prefer not to say) and were asked how their gender identity compared to their sex registered at birth with three possible responses being coded (Cis, Trans, Prefer not to say). [3] The researchers looked at the responses to two questions in the survey: 

“Which, if any, of the following long-term conditions do you have?”, with one option being “A mental health condition”  "During your last general practice appointment, did you feel that the healthcare professional recognised and/or understood any mental health needs that you might have had?"  Out of 1,520,457 people who responded to the survey, 7,994 (0.7%) were transgender, 1,499,852 (98.3%) were cisgender and 12,611 (1.0%) preferred not to say. Importantly, 2,600 (0.3%) non-binary people and 2,277 (0.2%) people who chose to self-describe their gender responded to the survey, allowing the researchers to look at outcomes for these groups who are rarely represented in health statistics.  

After controlling for age, the researchers found all transgender patients and cisgender non-binary patients had a higher risk of reporting a long-term mental health condition than cisgender men and women.  

The highest risk was for transgender non-binary patients, of whom one in two reported having a long-term mental health condition (47.2%). For transgender men and women and for cisgender non-binary patients, the risk was roughly one in six (16.4%, 15.9% and 15.8% respectively). The risk for cisgender men and women was the lowest at one in ten (8.8% and 12.0%).   The survey did not ask for details of the mental health condition, but previous research has indicated common mental health conditions such as anxiety and depression, as well as eating disorders, self-harm and suicidality are more common amongst transgender, non-binary, and gender diverse groups, whereas severe mental illnesses such as schizophrenia or bipolar disorder are thought to occur at rates similar to those in the binary cisgender population. [4] 

Alongside investigating the frequency of mental health conditions, the researchers also looked at how well people’s mental health needs were met at recent general practice appointments. Out of those who reported that their mental health needs were relevant to their last appointment, approximately one in six cisgender men and cisgender women reported their mental health needs were unmet (15.6% and 15.9% respectively), lower than all other gender identity groups which ranged between one in five (20.0%) and one in four (28.6%). 

“Poor communication from health-care professionals and inadequate staff-patient relationships may explain why trans, non-binary, and gender diverse patients were more likely to report their mental health needs were not met at recent general practice appointments. Changes are urgently needed for the NHS to become a more supportive service to transgender, non-binary, and gender diverse patients, including improved recording of gender across health-care records systems and staff training to ensure health-care professionals meet the mental health needs of all patients, whatever their gender,” says Dr Ruth Watkinson, Research Fellow, The University of Manchester and lead author on the study. [1] 

Jack Tielemans from The Proud Trust and a co-author of the paper adds, “Empowering young LGBT+ people to be proud of who they are through youth groups, mentoring programmes and societal support, alongside inclusive healthcare, are important in tackling the higher risk of mental health conditions amongst trans, non-binary, and gender diverse young people.” [1] 

The authors note several limitations of their study, including that pooling data from two survey years may mean some participants were resampled in consecutive years leading to biased estimates.  Additionally, the clinical language in the survey (long-term mental health condition) and that it relied on self-reporting, may have influenced which patients report a mental health condition. A small proportion of people responded “prefer not to say” to gender-related questions in the survey. The authors suggest there may be numerous reasons for this choice ranging from privacy concerns to patients feeling there was no suitable response for them. There was a high prevalence of unmet mental health need amongst this group which authors say highlights the importance of including this response option, and of further research to understand the make-up and needs of this patient group.

NOTES TO EDITORS

This research was funded by the Department of Health and Social Care (DHSC) and the National institute for Health and Care Research (NIHR) as part of a mental health research initiative awarded to the NIHR Applied Research Collaboration Greater Manchester (ARC-GM) designed to tackle the disparity between regional needs and mental health research activity. More information about the funding award is available from here. 

The study was conducted by researchers from the University of Manchester in collaboration with staff from The Proud Trust and LGBT Foundation.

[1] Quote direct from author and cannot be found in the text of the Article. 

[2] https://www.gp-patient.co.uk/   

[3] For a comprehensive list of LGBT+ and gender identity terms and definitions, the authors suggest: https://www.stonewall.org.uk/list-lgbtq-terms 

[4] Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgender Health 2022; 23: S1–259. 

For the risk of a self-reported long-term mental health condition in all gender identity groups, please see Figure 2 in the paper. 

 

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