by Gianna E. Israel
Copyright © 1996, all rights reserved.
Depression is the leading mental health issue faced by transgender persons. However, unless a client or reader's depression has progressed to crisis proportions it is the subject I am least likely to receive questions about. Depression is also the leading mental health issue faced by those who do not have a transgender identity. With this knowledge it should be clearly understood that when transgender persons are depressed, it does not mean that having a transgender identity or fulfilling one's crossdressing needs is pathological, mentally disordered or medically diseased.
Both transgender and non-transgender populations are equally unlikely to receive treatment for depression. This is tragic, because depression is one of the best understood mental illnesses, with recognizable symptoms and effective interventions. People do not seek treatment for a variety of reasons. Some individuals allow themselves to suffer tremendous pain, believing that obtaining help is shameful or a sign of weakness. Typically these persons have bought into the notion that mental health issues are stigmatizing or less important than medical conditions. In other words, people are more likely to seek treatment after contracting a painful, sexually-transmitted disease than get help for depression. It does not seem to matter how much emotional turmoil the person is suffering.
Within both populations, there also exist numerous persons who recognize that they are moderately to severely depressed. Some of these individuals do not seek treatment because they believe it will be ineffective or they are suspicious of the medical and mental health professions. Because transgender persons continue to be discounted, misdiagnosed or characterized as pathological, particularly by professionals unfamiliar with gender identity issues, it is understandable that some will feel hesitant in seeking support for depression. This concern is an important dynamic in supporting transgender persons. I will address it after providing basic information about depression itself and how it is identified.
Depression is a mood disorder characterized by extended feelings of sadness, loss, restlessness, discouragement, hopelessness, self-doubt and guilt. These feelings are often accompanied by noticeable changes in a depressed individual's regular sleeping, eating and sexual habits. They are also likely to have changes in self-perception, think negative thoughts on an on-going basis, have difficulty making decisions, and sometimes, contemplate self-destructive acts. Their emotions typically swing sharply between feeling angry, sad, melancholic or moody.
Depression is not about having one or several isolated bad or low-energy days; its about feeling badly and having an emotionally poor quality of life, day after day, with no hope of relief in sight.
The preceding description reflects the state of mind that characterizes depression and lends understanding to why people do not seek treatment. The more severe the depression the more limited an individual's ability to think realistically or recognize options which might improve their quality of life. Simply stated, most depressed persons routinely discount treatment options until everything else has failed. This type of "clouded" judgment also frequently slows the resolution of gender issues. Depressed transgender persons frequently feel compelled to move ahead in their transition without seeking adequate support. Also, in order to gain acceptance and reduce emotional turmoil, they may disclose their transgender issues without having taken into account potential consequences or its effect upon others.
It is well documented within professional literature that depression can be caused by either one or a combination of medical, psychological or circumstantial factors. As a result there are a variety of treatment approaches which are designed to address this disorder. Therefore, while it is a positive step for people to acknowledge they are depressed, deciding ones' own course of treatment or self-medicating is irresponsible and dangerous. A professional familiar with the treatment of depression should be consulted. In some circumstances anti-depressant medications may be useful, particularly when an individual is in crisis or experiencing debilitating emotional pain. Most anti-depressants are designed to take the edge off of the extreme lows or sharp mood swings which accompany severe depression. They provide temporary emotional relief allowing the individual an opportunity to build coping skills. Anti-depressants vary in their recommended length of use and several also address depression-related anxiety or manic-depression.
Education within individual psychotherapy also plays an important treatment role and may be coupled with medication.. In learning about depression, people frequently feel that the tremendous pain they are suffering will never end. Being reassured that despondent feelings do resolve and that positive change is possible is an important part of treatment. It is also helpful for people to find out that they are not alone, and that there are numerous instances of successful treatment. Because depression exacerbates social isolation, peer support or group therapy can provide individuals with positive social contacts and an opportunity to hear how others combat depression.
It should be noted that in providing depression treatment to transgender persons, there exist several dynamics which frequently prevent persons from seeking help. As previously mentioned, transgender persons routinely have been characterized as mentally disordered because their crossdressing and gender identity issues seem unusual to non-transgender persons. Regrettably such attitudes still exist today within the medical and mental health professions, particularly in locations that do not have access to up-to-date professional literature on gender identity issues. Both care providers and transgender persons should understand that having a transgender identity or individual crossdressing needs does not cause depression; rather they are caused by experiencing seemingly irresolvable social and circumstantial pressures. Learning effective coping skills which concurrently resolve these pressures while preserving a person's gender identification is the correct approach in these situations.
Transgender persons also avoid treatment for depression because it is widely believed that in order for treatment to be effective, both gender identity and depression issues must be addressed at the same time. This is not always the case. In some situations it is possible to provide symptom relief without having to immediately deal with gender identity issues. Individuals may seek support for their depression, stressing that they are not interested in discussing gender identity issues until they feel safe doing so, if it should it become necessary. Those who feel that disclosing their gender issues may prove compromising or be met with negativity, may choose not to. Rather, they can utilize the break from emotional anguish which is available through traditional depressive-symptom relief to seek gender-specialized resources for their crossdressing or gender identity issues.
Having two care providers, one who dispenses depression treatment and the other who offers gender-specialized support is useful in many circumstances. This is particularly so when a transgender person does not yet have a sufficient level of communication skills and knowledge about gender identity issues to disclose to a helping professional unfamiliar with gender identity issues.
The interpersonal difficulties and social hostilities which transgender persons experience can play a large role in causing or aggravating depression. This is particularly true for individuals who are coming to terms with gender issues without the assistance or awareness of gender specialized resources. "Coming-out," disclosure concerns, balancing transition costs, social isolation, family rejection, and being single or unable to find acceptance from a significant other, are some of the recognizable sources of depression in transgender persons. Less frequently acknowledged contributors to depression include; unresolved gender identity conflicts in pre and post-operative persons, pre and post-surgical emotional adjustment, poor body image and low self-esteem.
Transgender hormone administration also may play a causal role in depression. Because hormones are powerful chemicals, an increase or decrease in dosage can bring on changes in mood. Transgender persons and their physicians need to recognize that routine laboratory testing of blood-based hormone levels helps insure that dosages are effective, yet not so high as to create debilitating mood swings or dangerous medical complications. Gradual changes in hormone dosages are a sensible precaution that provide an opportunity for physical and emotional adjustment. Also, individuals who are initiating hormone administration frequently are poorly prepared for the emotional changes that go with it. These persons are encouraged to adjust their thinking and seek support for their needs much as women do during menopause. This is particularly so for transgender women who choose to cycle their hormones so as to mimic the biological rhythms genetic women experience.
Lastly, care-providers need to be aware that a lack of access to hormones also produces high rates of depression, emotional mood swings, and occasionally suicidal feelings. This is particularly so when public institutions, and medical or mental health providers deny transgender persons access to hormones because it is against policy or care-provider staff are unfamiliar with gender identity issues. Transgender persons should not be denied access to hormones or cut-off from pre-existing prescriptions solely because a care-provider is disinterested or unfamiliar in supporting transgender persons. Transgender hormone administration is a routine medical procedure and transgender persons are no less entitled to informed medical care than other patients.
Transgender persons can suffer depression caused by situations or disorders that are in no way related to gender issues. Transgender persons need to recognize this, and research treatment options before things reaching a crisis. It is senseless for individuals to suffer from depression when successful treatment options exist. In many circumstances severe and long-term depression can be halted with early intervention.
If you are a person suffering from depression, start searching for help now and do not give up until you find it. Most gender-specializing care providers are familiar with treatment and available resources. If you do not have a gender specialist in your area, traditional mental health counselling and psychiatric resources are listed in the "community section" of your local telephone directory. Lastly, if you would like to read more about combating depression, most bookstores and libraries have numerous professional and self-help titles available. One I recommend is The Depression Workbook, by Mary Copeland, M.S. (New Harbinger Press).