Mental Health and Mental Health Treatment Experiences of Transgender and Gender Diverse Persons
Background: Stigma, discrimination, and victimization are common occurrences in the lives of TGGD persons (e.g. non-binary, genderqueer, agender, and other non-cisgender identities) in the U.S., including occurrences in healthcare settings. Additionally, TGGD people in the U.S. experience numerous disparities related to physical health, mental health, substance use, and health risk behaviors. Suicide prevalence data provide the strongest and most urgent indication that healthcare organizations, and mental health providers specifically, are not optimally meeting the needs of this marginalized, at-risk population. TGGD persons have experiences of stigma and discrimination in healthcare settings, and these experiences are directly associated with provider behaviors, staff cultural competence, and institutional policies/practices. Minority Stress Theory suggests that experiences of stigma are directly linked to health outcomes and health disparities. It also suggests disparities may be mitigated by one’s internal coping skills and by level of support available from affirming others. Purpose: This dissertation’s research sought to better understand the relationship between stigma/discrimination and sexual/gender minority (SGM) population health and to better understand the experiences of TGGD persons who receive mental health services in the United States. Therefore, this dissertation begins to address this critical need and fill the gap in science. Three discrete manuscripts are proposed to fully explicate three concepts: 1) How state-level policies may affect SGM mental health (a secondary data analysis); 2) A comprehensive understanding of TGGD persons’ mental healthcare experiences (an integrative review); and 3) TGGD persons’ inpatient mental healthcare experiences (a qualitative study). Methods: First, we conducted a secondary data analysis examining state-level inclusivity for SGM populations, and relationships with indicators of mental health and health risk behaviors in those states; we sought to determine whether and to what extent there is a relationship between states’ SGM policies and practices, and the mental health and health risk behaviors of those states’ SGM residents. Second, we conducted an integrative review examining the mental health treatment experiences of TGGD adults; we sought to synthesize and characterize the existing health literature regarding the mental health experiences of TGGD adults. Third, we conducted a qualitative descriptive study examining the inpatient mental health and substance disorder treatment experiences of TGGD adults; we sought to better understand the inpatient mental health and/or substance treatment experiences of TGGD persons and to identify and characterize facilitators of/barriers to gender-affirming care in inpatient mental health and/or substance treatment settings. Results: In Chapter Two of this dissertation, an ecological secondary analysis of the BRFSS data set showed statistically significant relationships between LGBTQ persons’ state of residence and self-reported mental health symptoms and risk behaviors of the LGBTQ persons who live there. Restrictive state policy environments were shown to function as a distal stress factor and inclusive state policy environments were shown to function as a resilience factor. In Chapter Three of this dissertation, integrative review results suggest that TGGD persons experience incidents of stigma and discrimination in mental health treatment settings. In Chapter Four of this dissertation, participants reported both stigmatizing aspects and welcoming/affirming aspects of inpatient mental health/substance treatment experiences. Conclusions: This dissertation explored the mental health of TGGD persons through a Minority Stress Theory conceptual framework, including potential distal stress factors, proximal stress factors, and resiliency factors. This program of research has made substantial and meaningful contributions towards an enhanced understanding of TGGD mental health experiences, sources of TGGD stigma, and sources of coping/resiliency. In each chapter, findings suggested the presence of MST concepts of distal stress factors, proximal stress factors, and resiliency factors. Nursing remains underrepresented in health literature, and dissertation results highlight ample opportunities to advance TGGD population health through nursing practice, nursing education, nursing scholarship, and nursing policy.