Expecting rejection is a "pervasive" daily source of internal stress for transgender and gender-nonconforming (TGNC) individuals, on par with experiencing actual rejection, new research shows.

TGNC individuals often suffer experiences of stigmatization, discrimination, and violence, which contribute to psychological distress and other adverse health effects. Yet, little is known about internal stressors faced by TGNC individuals regarding the expectation of rejection or other negative attitudes.

To investigate, Brian Rood, PhD, MPH, of the Department of Psychology, Augsburg College, Minneapolis, Minnesota, and colleagues conducted in-depth interviews with 30 adults (mean age, 30.4 years) who identified as TGNC.

In the study, which was published in the August issue of Transgender Health, most of those interviewed identified as women or as transmen (female-to-male persons). The majority of participants had either graduated from college or had taken college-level course work and reported engaging in masculinizing or feminizing hormone therapy. In addition, most had also considered some form of gender reassignment surgery and had told people at work or school about their affirmed gender.

Overall, participants noted that the expectation of rejection in most environments is almost inevitable and is a fundamental part of being identified as TGNC, the authors report.

One 40-year-old white, gender-fluid interviewee said: "There is the knowledge that you're going to walk into places and you will get treated differently; you will get looked at differently. It's not like it might not happen. It's not like it might happen. It's going to happen at least at some point every day."

"Overwhelming, Crushing, Awful"

Overwhelmingly, participants said they expected rejection in places where they had to interact with others in a way that made their gender identity explicit. The most frequently cited places were public restrooms, locker/fitting rooms, and healthcare facilities.

Stressful situations included instances requiring legal identification, for example, going through airport security or being stopped by police. In such situations, avoidance often is not an option.

The expectation of rejection often causes distinct feelings of fear and worry concerning personal safety, the study showed.

"Nearly universally, participants shared a common concern for the possibility of being a target for discrimination and victimization as a result of their gender identity," the authors note. Feelings of anxiety and stress as well as mood disturbances ― primarily feelings of sadness and depression ― also accompanied expectation of rejection, as did anger, frustration, and disappointment.

The TGNC adults described the internal stress as "overwhelming, crushing and awful."

One third of the total sample reported the use of alcohol and smoking cigarettes as common coping strategies. Participants also mentioned using marijuana, prescription drugs, and other unspecified substances.

These observations, researchers note, suggest that expecting rejection is a "frequent and salient internal stressor for TGNC individuals. Therapeutic interventions are needed to address the specific cognitive, emotional, and behavioral responses TGNC individuals experience as a result of the stress associated with expecting rejection, including fear, anxiety, and situational avoidance."

Given the frequency with which internal stressors were reported by the participants, "there is a clear need and urgency to further evaluate the cumulative impact of the stress over time and identify future targets to intervene upon to mitigate potential harms," Dr Rood and colleagues conclude.

"Troubling" Insights

Commenting on the findings for Medscape Medical News, Robert Garofalo, MD, director of the Center for Gender, Sexuality and HIV Prevention at the Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Illinois, said the findings are "important from a public health perspective.

"These troubling qualitative interviews document with rich context an array of negative social realities experienced by far too many transgender individuals ranging from interpersonal violence and harassment to more subtle forms of rejection that stem from ill-advised public health policies regarding the use of public restrooms," he said.

"Identifying and documenting public health disparities resulting from experiences of rejection, as the authors have done here, is an important step in creating change to eliminate them," Dr Garafalo added.

These observations, he said, give healthcare providers insight into the different kinds of rejection experienced by transgender people and the impact it has on health conditions, such as anxiety and depression.

"Our hope is that work like this can help give providers a framework for asking their patients about their lived experiences and facilitate the identification or diagnosis of clinical conditions which might require medical or behavioral health interventions. They also might help identify patients in need of community-based referrals for peer or other types of social support," he said.

The findings in this study are not surprising to Lin Fraser, EdD, a psychotherapist in private practice in San Francisco, California. As a clinician who treats transgender people, "It's what I hear all day, every day in my practice," she told Medscape Medical News. Dr Fraser is past president of the World Professional Association for Transgender Health (WPATH) and is co-chair of the WPATH Global Education Initiative.

This study is unique, Dr Fraser said, because to date, the bulk of the research has been about negative things that actually happen, "not the anticipation of it and the fears and day-to-day reality of what it's like to go out in the world when you're trans ― particularly, I think, when you are just starting, although this study doesn't address that.

"For most people, as they have more time being out in the world as themselves, they may develop more resilience and coping skills," especially if they have "communities of support," Dr Fraser noted.

What can healthcare providers do? For one thing, "It's worth reminding transgender people that what they are doing is really a courageous act," Dr Fraser said.

The study had no commercial funding. The authors have disclosed no relevant financial relationships.

Transgend Health. 2016;1:151-164. Full text