Like soldiers returning from war, people who are transgender live lives on high alert, expecting everyday interactions with the gender-conforming world to turn negative or even violent.

This expectation of rejection and anticipation of negative interactions fuels the internal and external lives of transgender and gender nonconforming (TGNC) individuals, leading them to experience high rates of fear, anxiety, isolation, substance abuse and even suicide, according to Brian Rood, Ph.D., MPH, assistant professor of psychology at Augsburg College. From 2014-2015, Rood and a group of his colleagues conducted a survey of 30 adults who identified as TGNC. They found that not only actually experiencing negative reactions or rejection for their gender identity but simply the fear of such reactions carried similar negative impact. Rood’s research was published in the August 2016 issue of Transgender Health.

Rood, who is in his second year on the Augsburg faculty, spent the first part of his career in the field of public health, studying HIV prevention. He self-funded the mixed-method research, known as the Transgender Stress and Health Study; study participants were reimbursed with gift cards.

“The NIH doesn’t prioritize transgender research,” Rood told me when we talked late last month. “When you look at where the money is going, it primarily goes to HIV-focused research with gay men. Mental health research with transgender individuals is a low priority at this point. It is incredibly difficult to get funding for transgender issues unless you are a prolific researcher who is good at getting funds.”

Article continues after advertisement

During our conversation, the affable Rood detailed his research, his findings and his hopes for their larger impact.

MinnPost: What got you interested in research on transgender mental health?

Brian Rood: I started my research experience in public health, in HIV prevention. I worked in that area for several years. In research about the AIDS epidemic, the focus was on cisgender gay men. Over time, I realized that even in queer research there is a big priority placed on the experiences of gay men.

Over the years, it became clear to me that there wasn’t enough attention given to transgender health, which is sad. That realization got me interested in persuing research on transgender health and mental health. Very few people were doing this kind of research when I got started. I wanted to increase visibility on the topic and share the narratives of trans people.

MP: Your research is focused on the concept of social stress and its larger impact on the lives of transgender people. Are there other researchers working on similar topics?

BR: Ilan Meyer from UCLA developed a model called the Minority Stress Model. The short of it is that when you compare primarily gay and lesbian people with straight or heterosexual individuals, there are disparities when it comes to mental health, depression, anxiety and suicide. There are a lot of questions about of why that is. Meyer’s model helps us to understand that individuals with a minority identity like being gay or lesbian will experience unique types of stress. Those stress experiences include not only inactive, external experiences with stress — those that happen to a person from the outside — but also something called internal or proximal stressors that originate within a person. Trans people experience those same stressors but to an even greater degree.

MP: What is an example of an external or enacted stressor?

BR: When it comes to transgender research, the majority of studies focus on external or enacted experiences, like discrimination, violence and stigma — negative things that happen to trans people. We know there are a lot external stressors going on in the trans community. One example would be the high rate of murder of trans people. Another would be workplace discrimination.

MP: Can you give me an example of an internalized or proximal stressor?

Article continues after advertisement

BR: Internalized stressors for trans people include internalized stigma, identity concealment and fear of rejection.

Courtesy of Augsburg College Brian Rood

An example of identity concealment would be a trans person who hides who they are out of fear of something bad happening to them if someone figures out. This could also include someone who identifies as gay but doesn’t come out because they are afraid of violence or their family rejecting them. Internalized sigma includes internalized homophobia. When we hear these negative messages about homosexuality, we begin to internalize them and ultimately believe them.

The third type of internalized stressor is the expectation or fear of rejection. This would be is if someone worries that because of their identity if they go somewhere in public something bad might happen to them. An example of fear of rejection would be if a trans person thought, “I’m worried about using the restroom because someone might attack me if they realize that my gender identity doesn’t match my sex assigned at birth.” This would be a highly stressful situation for someone to anticipate or worry about happening.

While there is much work being done on external stressors, there is almost no research on the internal experiences of trans people. That’s what led me to take on this research.

MP: How did you find your study participants?

BR: All of the recruitment was done online. Participants have to live in the United States, be over the age of 18 and identify as transgender. They also had to affirm their authentic gender in some way. We sent fliers to listservs and closed online social networking groups. In the end, we collected 300 surveys from across the country. From those 300 participants, we randomly selected 30 to participate in in-depth interviews.

We got participants from across the country. We split participants up based on the census data. We had people’s ZIP codes split into the West, South, Midwest, East. We found participants from all of these regions.

MP: What are the ethics of online research? How do you confirm that participants are who they say they are?

BR: There are limitations to online research. It is difficult to fully verify the responses of individual participants, for instance. But we’ve found through decades of online research that the people who participate in these studies usually take a lot of time answering researchers’ questions. They are invested in this research and their answers tend to be honest. Individuals all provided us with their contact information, including email address.

Article continues after advertisement

MP: Once you identified your participants, how did you interview them?

BR: Once a participant was approved for the final round of interviews, we scheduled a telephone appointment. The interviews lasted as long as an hour and a half, and were done via Skype. We turned off the Skype video component during the interview to protect participants’ anonymity.

MP: Why was that important?

BR: With research in general the number No. 1 priority is the safety of participants. It is essential that we engage in practices that don’t put them at risk and that they can participate without anyone knowing. It was essential that we keep participation as anonymous as possible. We remove all identifying information.

MP: What kinds of questions did you ask in the interviews?

BR: We’ve structured the interview to assess for different components of Meyer’s minority stress models. For example, for the “expectation of rejection” question, I asked participants, “Have you ever expected that you’d experience rejection because you are transgender?”

MP: What were some of your findings?

BR: We learned where our participants expect to experience rejection. We learned about the specific thoughts and feelings associated with this expectation of rejection and we learned how they respond to rejection when it occurs — what are their various coping strategies.

MP: Where did your participants tell you they expect to be rejected?

Article continues after advertisement

BR: We found overwhelmingly that transgender participants reported that they felt rejection could happen anywhere. As a cisgender person, this reality felt sobering and sad. A transgender person believes, “Anywhere I go I’m worried that something bad could happen to me.” For a cisgender person, that’s not usually the case. Our trans participants said that they felt they could be anywhere and they would be worried about rejection or safety.

MP: Did any areas feel like true danger zones to your participants?

BR: Hands down, our participants told us that public restrooms created the most stressful situation for them.

They told us they experience stress and hypervigilance whenever they enter a restroom. They described routines of scanning the bathroom to see who’s in there and who’s not. Sometimes they’d sit in the stall and wait until everyone left the bathroom before going out to wash their hands. They train themselves not to make eye contact in bathrooms, to stay quiet and not draw attention to themselves. They overwhelmingly described this horrible stress. Some people want to keep trans people out of restrooms because they are afraid they are predators. In reality we know that trans people are actually the ones who are more likely to be violated in restrooms, that they have a lot of trauma around that experience.

We also heard from our participants about going to airports and experiencing TSA exams with full-body pat downs. The threat of these situations is a constant source of stress.

MP: How did this fear of rejection manifest itself in study participants?

BR: The most common emotions expressed by the transgender people we interviewed were anxiety and stress. Everyone we interviewed mentioned the experience of worrying about what could happen to them because of their gender identity. It was stressful and anxiety provoking.

The next-most prevalent response to the fear of rejection was a fear about their personal safety. Our participants also described feeling stress and self-loathing or shame and anger over having to worry about their safety. Many said they felt exhausted at the end of day. They are drained by worrying about what could happen to them.

MP: What impact did these fears have on participants’ health or quality of life?

BR: The most frequent coping response to expecting rejection was avoidance. If participants think they might be targeted for their gender identity, their response was often to avoid the situation altogether or escape. That makes for a pretty limited life.

The limited research that we have on transgender mental health focuses on reactions associated with experiencing discrimination, violence or stigma. We have evidence to support that experiencing those situations connected to stress, substance abuse and depression.

MP: Is the physical/emotional response to internalized stressors different than it is to external stressors?

BR: We found that our participants were constantly experiencing feelings of being “on edge,” sad or isolated. Often their response was substance use. What we found was that internal stressors could have the same type of psychological impact as an external experience. We found that worrying that you might be victimized could have a similar effect on a person’s mental health as actually experiencing real-life victimization.

Participants reported that on a daily basis they are constantly wondering or worrying and scanning their environment and making sure they have an escape plan. We would imagine that there is something about that experience that would be associated with an anxiety disorder or a mood disorder.

MP: This sounds like some of the symptoms of PTSD.

BR: I’m a clinical psychologist by training. I’ve worked with a lot of people with PTSD. Some of the common symptoms of PTSD include avoiding certain situations, reacting to certain cues in your environment, being on guard, having distressing nightmares. These narratives of fear, anxiety, hypervigilance and constant worry that we collected from our trans participants seem to be parallel to someone who’s had a traumatic history.

MP: What can care providers do to help transgender people cope with these stressors?

BR: I think health providers really need to be attuned to the internal stressors that trans individuals are likely facing. They are pretty well attuned to asking about external stressors, but it’s not very common that health providers know to ask about these internal stressors, about their internal experience.

MP: Are there ways that public policy can be changed to make life easier for transgender people?

BR: All the research that we have shows that we really ought to be allowing trans individuals to use their preferred restroom. Otherwise they are at greater risk of being victimized. These are stressful situations. Trans people want to use the restroom and get in and out like any other people. They don’t have larger motivations.

Research like this could inspire public policy, laws and regulations about trans individuals, protecting the rights and safety of individuals because they are so commonly targeted and misunderstood in our society. I believe and hope that my research will help to inspire such things.