Now more than ever, psychiatry must champion policies that protect transgender and nonbinary (trans) people’s rights, dignity, and access to care. Since 2016, anti-trans legislation—restricting health care, public accommodations, legal recognition, and education—has surged, worsening existing population-level public health crises. In 2024 alone, 669 anti-trans bills were introduced across 43 states—a 3,086% increase since 2015. Executive orders enacted in early 2025 further stripped trans people’s rights. One such order encouraged the Attorney General to apply the federal statute on female genital mutilation to gender-affirming surgery for trans men, raising the possibility of criminal prosecution. Additionally, these orders threaten financial penalties—such as the potential withdrawal of federal funding from health care systems that provide gender-affirming care to people under 19 years old—creating serious legal and economic risks for clinicians and systems that deliver lifesaving, evidence-based care. Within this landscape, psychiatry has an ethical duty to advocate for policies that safeguard both trans people and their health care providers.

Link to article in American Journal of Psychiatry

Abstract

In 2017, we called for multisector public health initiatives to address discrimination and violence against transgender and non-binary communities, offering tangible recommendations for protecting the rights, safety, and wellbeing of transgender and non-binary people. Since 2017, notable advances in transgender rights have emerged in parts of Asia and Europe, including bans on conversion therapy in India, legal gender recognition in Hong Kong, and the provision of gender-affirming care for transgender youth in Germany, Switzerland, and Austria. However, as of 2025, the urgency of our call has intensified as increasingly discriminatory legislation are introduced across other regions, restricting gender-affirming health care, limiting legal gender recognition, and curtailing access to public spaces, sports, employment, and housing. This escalating global tide poses a profound social safety threat, resulting in devaluation, isolation, rejection, and exclusion. A coordinated multisector response rooted in social safety is urgently needed for transgender and non-binary communities—especially youths within these populations—to ensure reliable social connection, inclusion, and protection.

Link to article in The Lancet

Abstract

Introduction: There has been increasing attention to—and debate about—best practices related to gender measurement. We add to this conversation by testing whether an approach of providing participants with an extensive list of gender options and then having them self-select into a more limited group of choices (that cohere with the research questions) could be useful.

Methods: In this study of adults (N = 1813), in 2021–2022, we measured gender using a three-part approach: the Gender EXPAND (EXPANsive responsive genDer) approach. Participants were first asked if they identified as transgender. They were then asked their current gender (check all that apply: woman, trans woman, trans feminine, man, trans man, trans masculine, nonbinary or genderqueer, agender, and an option to write in a response). Participants then selected a gender that best fit for them from a limited set of options (transgender, cisgender, nonbinary, unsure).

Results: We evaluated researcher reclassification from the expanded list of gender options compared to participant self-selection from the limited gender categories. We miscategorized 10.5% of participants when reclassifying their gender from the extensive list of options compared to their self-identification as transgender. We miscategorized 11.2% of participants compared to participants’ self-selection as cisgender, transgender, nonbinary, or unsure.

Conclusions: Participants generally responded well to the Gender EXPAND approach and our transparency in our explanations for our questions. This approach should be refined to reduce misclassification, potentially through different reclassification processes or modified response categories.

Policy Implications: Measurement of gender has downstream implications for representation in data, which informs policy. Inadequate measurement can lead to inaccurate data and undercounting of gender diverse individuals and further marginalizes transgender and nonbinary people at a time when stigma and anti-transgender legislation is at an all-time high.

Link to article in Sexuality Research and Social Policy

Abstract

Developing affirming interventions for transgender and nonbinary (TNB) therapy clients requires understanding their experiences with microaggressions in psychotherapy, yet no self-report measure of anti-TNB microaggressions in this context exists. Moreover, few studies have tested the associations between anti-TNB microaggressions and therapy processes. To better address the burden of unmet mental health care needs among TNB people, this three-study investigation designed and tested the psychometric properties of the Gender Identity and Expression Microaggressions in Therapy Scale (GIEMTS), a measure of TNB individuals’ encounters with microaggressions in psychotherapy. Study 1 (N = 225) identified a four-factor model, comprising the themes of Educational Burdening, Lack of Affirmation, Inflation, and Invalidation. These subscales exhibited strong internal consistency reliabilities and demonstrated convergent and discriminant validity. The results of Study 2 (N = 435) replicated the four-factor structure through confirmatory factor analysis. However, bifactor analysis revealed that the Educational Burdening, Inflation, and Invalidation subscale scores were mostly accounted by a General Anti-TNB Microaggressions scale score–though Lack of Affirmation showed evidence of its independence. Also in Study 2, both scales were uniquely negatively associated with the working alliance. Study 3 (N = 151) found evidence for the test–retest reliability of GIEMTS scores over a 2–3-week period. Overall, the GIEMTS emerged as a robust and psychometrically sound instrument that captures the experiences of TNB individuals in therapy settings. The study concludes with valuable recommendations for training and clinical practice to bolster TNB mental health.

Abstract

Purpose: Sex work is a common form of work among young trans women (YTW).

Methods: Using an occupational health frame, we measured associations between demographics, sex work, and vocational outcomes in 18-month visit data from the SHINE study (n=263, San Francisco).

Results: Overall, 41.8% reported lifetime sex work, primarily escorting/paid sex. Motivations included “better pay” and “can't get a job due to gender discrimination.” Occupational injuries included anxiety (53.6%) and depression (50%), with significantly higher relative risk for YTW doing multiple types of sex work. Criminalization experiences (i.e., incarceration, arrests, and police interaction) were common.

Conclusion: Results echo calls for sex worker-affirming mental health care for YTW.

To Cite: Fisher, M. R., Turner, C., McFarland, W., Breslow, A. S., Wilson, E. C., & Arayasirikul, S. (2021). Through a different lens: Occupational health of sex-working young trans women. Transgender Health. https://doi.org/10.1089/trgh.2021.0109

Abstract

Background: For transgender people, reaching transgender (trans)-specific developmental milestones, including recognizing and expressing one’s identity, plays an integral role in overall health, wellbeing, and the pursuit of gender affirmation. Yet trans people continue to face minority stressors, including structural violence (i.e., discrimination, violence, and stigma), which may interfere with the achievement of these milestones. Among trans women specifically, however, potential associations between gender developmental milestones and structural violence are not well characterized in the literature. In a sample of Filipinx (i.e., an inclusive term for describing non-binary genders in the Philippines) trans women who are sexually active with men (trans-WSM), we thus sought to: (a) describe the mean ages at which gender developmental milestones occur and (b) examine the associations between structural violence and mean ages at which at which Filipinx trans-WSM experience trans-specific developmental milestones.

Methods: Using data from Project #ParaSaAtin, an online survey of Filipinx trans-WSM (n = 139), we mapped age-estimates per trans-specific milestones and then tested whether structural violence is associated with the mean age at which trans women experience trans-specific developmental milestones.

Results: Overall, participants who reported higher levels of discrimination, stigma, and violence also experienced a later age for nearly each milestone (i.e., initial self-awareness of transfeminine identity, transfeminine expression in private, transfeminine expression in public, first consensual oral/vaginal/anal sex with a cisgender male partner, first consensual oral/vaginal/anal sex with a cisgender male partner as a trans women, and hormone integration) (all p-values <0.05). Of note, the single exception to this pattern was the non-significant association between stigma and initial disclosure of transfeminine identification to another person.

Conclusion: Results are consistent with psychological literature outlining a temporal sequence of developmental milestones among young trans-WSM. For young trans-WSM in the Philippines, data from this study demonstrate significant associations between structural violence and the achievement of developmental milestones. These findings highlight the need for trauma-informed, strengths-based programming and institutional policies that measure and mitigate anti-trans violence.

To Cite: Restar, A. J., Breslow, A. S., Jin, H., Quilantang, M. I., Sison, O., Bermudez, A. N., ... & Nazareno, J. (2021). Transgender-specific developmental milestones and associated experiences of violence, discrimination, and stigma among Filipinx transgender women who are sexually active with men. Plos One, 16(3), e0248248. https://doi.org/10.1371/journal.pone.0248248

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Abstract

The extent to which violent victimization may explain higher rates of suicidality for transgender and gender diverse (TGD) populations is not well-understood. We identified likely-TGD patients using 2008–2019 electronic health record data and compared them with non-TGD patients to characterize differences in suicide attempt, ideation, and violent victimization. TGD patients (n = 916) had more suicide attempts (5.2 vs. 0.4 percent), ideation (20.5 vs. 1.8 percent), and violent victimization (5.4 vs. 1.7 percent, all p < .001) than non-TGDs (n = 511,026). Violent victimization and TGD cohort were independent predictors of suicide attempt (odds ratios [ORs], 7.23 and 10.84) and ideation (ORs, 6.83 and 11.03, all p < .001). We did not observe a differential impact of violent victimization for gender minorities. TGD patients are at higher baseline risk for suicidality, which is higher still for those experiencing violent victimization. Routine screening for both outcomes, including in primary care settings, may improve treatment.

To Cite: Progovac, A. M., Tran, N. M., Mullin, B. O., De Mello Libardi Maia, J., Creedon, T. B., Dunham, E., ... & Cook, B. L. (2021). Elevated rates of violence victimization and suicide attempt among transgender and gender diverse patients in an urban, safety net health system. World Medical & Health Policy. https://doi.org/10.1002/wmh3.403.

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Abstract

Background: In recent years, Massachusetts (MA) and Rhode Island (RI) joined a growing list of states allowing residents to easily change the gender marker and name on government-identification (ID) documents. This was an important change for transgender and gender diverse (trans) residents, who face frequent mistreatment and thus for whom legal gender affirmation is critical. Little is known about associations between legal gender affirmation and psychological outcomes.

Methods: We examined associations between legal gender affirmation (i.e., having changed gender marker/name on neither, one, or both a passport and state ID), upsetting responses to gender-based mistreatment, and mental health outcomes in a sample of trans MA and RI residents. Analyses controlled for gender identity, age, race/ethnicity, education, employment, income, and insurance status.

Findings: Legal gender affirmation was significantly associated with lower reports of depression, anxiety, somatization, global psychiatric distress, and upsetting responses to gender-based mistreatment.

Conclusions: These data provide corroborate recent studies suggesting having pursued legal gender affirmation may be protective. Findings bolster calls to increase structural support for trans individuals, including enactment of state policies easing legal gender affirmation.

To Cite: Restar, A., Jin, H., Breslow, A., Reisner, S. L., Mimiaga, M., Cahill, S., & Hughto, J. M. (2020). Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations. SSM-Population Health, 11, 100595.

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Abstract

Purpose: To close gaps in transgender health research, we mapped trends in gender affirmation processes (i.e., social, legal, and psychological transitions) that are unique among nonbinary (NB) transgender adults when compared with transgender women (TW) and transgender men (TM).

Methods: Data were drawn from the Columbia Trans Empowerment Survey (N=707), an online national study conducted between 2014 and 2015 in the United States. We used one-way analysis of variance tests, chi-square tests, Kruskal–Wallis tests, and post hoc analyses to estimate differences in gender affirmation processes and transgender congruence between: (1) NB adults, n=271, 38%; (2) TW, n=291, 41%; and (3) TM, n=145, 21%. We then identified bivariate correlations between variables of interest.

Results: In the full sample (n=707), we found significant positive bivariate correlations between pursuing gender affirmation and transgender congruence. In terms of demographics, NB participants were significantly more likely to be queer (42.1%), polyamorous (25.5%), unemployed (44.8%), and younger (median=22) than TW and TM. They also reported taking significantly fewer gender affirmation processes, with significant differences between the three groups in terms of particular experiences. The NB participants also reported significantly lower rates of transgender congruence, specifically lower appearance congruence though similar gender identity acceptance.

Conclusion: The NB transgender adults in this sample report unique identity-related characteristics, including significantly lower rates of medical/social transition as well as decreased transgender congruence. These data are among the first to describe unique pathways by which NB adults, TW, and TM may pursue gender affirmation and interact with providers as they navigate congruence, transition, and well-being.

To Cite: Breslow, A. S., Wojcik, H., Cox, R., Tran, N. M., & Brewster, M. E. (2020). Toward nonbinary nuance in research and care: Mapping differences in gender affirmation and transgender congruence in an online national US survey. Transgender Health, 6(3), 156-163. https://doi.org/10.1089/trgh.2020.0038

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Abstract

Introduction: Suicidality is higher for gender minorities than the general population, yet little is known about suicidality in disabled or older adult gender minorities.

Methods: This study used 2009–2014 Medicare claims to identify people with gender identity–related diagnosis codes (disabled, n=6,678; older adult, n=2,018) and compared their prevalence of suicidality with a 5% random non–gender minority beneficiary sample (disabled, n=535,801; older adult, n=1,700,008). Correlates of suicidality were assessed (via chi-square) for each of the 4 participant groups separately, and then disparities within eligibility status (disabled or older adult) were assessed using logistic regression models, adjusting first for age and mental health chronic conditions and then additionally for Medicaid eligibility, race/ethnicity, or U.S. region (each separately). The primary hypotheses were that gender minority beneficiaries would have higher suicidality but that suicidality disparities would persist after adjusting for covariates. Data were analyzed between 2017 and 2019.

Results: Gender minority beneficiaries had higher unadjusted suicidality than non–gender minority beneficiaries in the disabled cohort (18.5% vs 7.1%, p<0.001). Significant suicidality predictors in all 4 groups included the following: age (except in older adult gender minorities), Medicaid eligibility, depression or behavioral health conditions, avoidable hospitalizations, and violence victimization. In age- and mental health–adjusted logistic regression models, gender minorities had higher odds of suicidality than non–gender minority beneficiaries (disabled, OR=1.95, p<0.0001; older adult, OR=2.10, p<0.0001). Disparities were not attenuated after adjusting for Medicaid eligibility, race/ethnicity, or region.

Conclusions: Heightened suicidality among identified gender minority Medicare beneficiaries highlights a pressing need to identify and reduce barriers to wellness in this population.

To Cite: Progovac, A. M., Mullin, B., Dunham, E., Reisner, S. L., McDowell, A., Sanchez Roman, M. J., Dunn, M., Telingator, C., Lu, F., Breslow, A. S., Forstein, M., Cook, B. L. Disparities in suicidality by gender identity among Medicare beneficiaries. American Journal of Preventive Medicine, 58(6), 757-898. https://doi.org/10.1016/j.amepre.2020.01.004

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Abstract

To understand developmental milestones among young transgender women (YTW), we mapped age estimates per milestone by race/ethnicity and cohort age using baseline data from Project Lifeskills (n=298). Compared with older and white participants, younger black, Latina, Asian, and other/mixed race transgender (trans) women reported earlier experiences of sexual debut, transfeminine identity disclosure to others, sexual debut as trans, transfeminine identity expression in public, and integration of hormone use. Findings call for increased research and utilization of gender-affirmative interventions among YTW, with incorporation of nuanced, intersecting roles of race/ethnicity and cohort age across milestones.

To Cite: Restar, A., Jin, H., Breslow, A.S., Surace, A., Antebi-Gruszka, N., Kuhns, L., Reisner, S.R., Garofalo, R., Mimiaga, M. J. (2019). Developmental milestones in young transgender women in two American cities: Results from a racially and ethnically diverse sample. Transgender Health, 4(1), 162-167. https://doi.org/10.1089/trgh.2019.0008

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Abstract

Synthesizing both objectification theory (Fredrickson & Roberts, 1997) and minority stress theory (Meyer, 2003), the present study used a pantheoretical model of dehumanization (Moradi, 2013) to examine body image concerns and disordered eating symptomatology with 205 transgender women from the United States. Objectification theory constructs (i.e., sexual objectification, internalization of sociocultural standards of attractiveness, body surveillance, body dissatisfaction) and minority stress-related variables (i.e., antitransgender discrimination) were examined as direct and indirect predictors of disordered eating. Results of a latent variable SEM (with a higher-order dehumanization factor comprised of sexual objectification and discrimination) generally provided support for our hypothesized direct and indirect relations. As expected, dehumanization was related directly to internalization and disordered eating and had significant indirect links to body surveillance, body dissatisfaction, and disordered eating via internalization. Potential implications of a pantheoretical model for future research with transgender women are discussed.

To Cite: Brewster, M. E., Velez, B., Breslow, A. S., Geiger, E. (2019). Unpacking body image concerns and disordered eating for transgender women: The roles of sexual objectification and minority stress. Journal of Counseling Psychology, 66(2), 131-142. https://doi.org/10.1037/cou0000333

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