1 s2.0 S0272735821001562 Main

Clinical Psychology Review 91 (2022) 102113
Contents lists available at ScienceDirect
Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev
Review
Associations between minority stress, depression, and suicidal ideation and

attempts in transgender and gender diverse (TGD) individuals: Systematic
review and meta-analysis
Michael J. Pellicane *, Jeffrey A. Ciesla
Kent State University, 600 Hilltop Drive, Kent, OH 44242, USA
A R T I C L E I N F O A B S T R A C T
Keywords: Minority stress theory posits that transgender and gender diverse (TGD) individuals exhibit greater rates of
Depression depression and suicidality due to internal (proximal) and external (distal) stressors related to their TGD identity.
Suicide Yet, the magnitude of the relationship between minority stress processes and mental health outcomes has not
Transgender
been quantitatively summarized. The current research meta-analyzed the relationship between minority stress
Minority stress
constructs and depression, suicidal ideation, and suicide attempt. Results from 85 cross-sectional quantitative
Meta-analysis
studies indicate that distal stress, expectations of rejection, internalized transphobia, and concealment are
significantly associated with increased depression, suicidal ideation, and suicide attempt. Greater effect sizes
were observed for expectations of rejection and internalized transphobia when compared to distal stress and
concealment. Future research on the relationship between minority stress, depression, and suicide would benefit
from longitudinal designs and more diverse and representative samples of TGD individuals.
Transgender and gender diverse (TGD) refers to individuals “who have Witcomb et al., 2018) and suicidal ideation and attempt (Haas et al.,
a gender identity that is not fully aligned with their sex assigned at birth” 2010; Marshall, Claes, Bouman, Witcomb, & Arcelus, 2016). They also
(American Psychological Association, 2015, p. 832).1 It is estimated that experience higher rates of other poor psychosocial and health outcomes,
approximately 0.1–0.7% of the population of the United States identifies including higher rates of HIV (Herbst et al., 2008; Niforatos, Wanta,
as transgender (Collin, Reisner, Tangpricha, & Goodman, 2016; Criss Durbak, Cavendish, & Yax, 2020), substance use (Gonzalez, Gallego, &
man, Berger, Graham, & Dalton, 2017; Flores, Herman, Gates, & Brown, Bockting, 2017; Hughes & Eliason, 2002), body dissatisfaction and
2016). With greater acceptance and public visibility of TGD people disordered eating (Coelho et al., 2019; Jones, Haycraft, Murjan, &
(GLAAD, 2020; Luhur, Brown, & Flores, 2019), the relative size of the Arcelus, 2016), and adverse childhood experiences (Schnarrs, Stone,
TGD population has risen in recent years, leading to an increase in de Salcido, Baldwin, & Nemeroff, 2019). The prevailing explanatory theory
mand for gender-affirming mental health services (Goodman et al., for these disparities is minority stress theory (Hendricks & Testa, 2012;
2019; Meerwijk & Sevelius, 2017; Wiepjes et al., 2018; Zucker, 2017). Meyer, 1995, 2003), which proposes that higher rates of mental disor
This change in demand for services demonstrates a need for clinical ders in TGD individuals results, not directly from being TGD, but from
psychologists to better understand the TGD community, including negative social, interpersonal, and psychological experiences related to
intervenable factors that contribute to its high vulnerability to depres their stigmatized minority status. This theory posits that there are two
sion and other mental health problems. primary types of minority stress. Distal minority stress includes “those
Transgender and gender diverse (TGD) individuals exhibit signifi external events that occur in the [TGD] individual's environment and are
cantly higher rates of negative mental health outcomes compared to related to either knowledge or perception of the individual's minority
their cisgender peers, including depression (Borgogna, McDermott, Aita, status” (Hendricks & Testa, 2012, p. 462). Proximal minority stress,
& Kridel, 2019; Connolly, Zervos, Barone, Johnson, & Joseph, 2016; meanwhile, comprises internal stress processes related to one's gender
* Corresponding author at: Department of Psychological Sciences, Kent State University, 600 Hilltop Drive, Kent, OH 44242, USA.
E-mail address: [email protected] (M.J. Pellicane).
1
Other commonly-used terms for this population include gender minority, gender-expansive, gender nonconforming, and gender-variant. Transgender and gender
diverse (TGD) will be used throughout this article as an umbrella term to refer to individuals whose gender identity does not match their sex assigned at birth and/or
whose gender expression does not conform to socially prescribed expectations and norms (Chen, Edwards-Leeper, Stancin, & Tishelman, 2018).
https://doi.org/10.1016/j.cpr.2021.102113
Received 24 August 2021; Received in revised form 13 December 2021; Accepted 16 December 2021
Available online 24 December 2021
0272-7358/© 2021 Elsevier Ltd. All rights reserved.
M.J. Pellicane and J.A. Ciesla Clinical Psychology Review 91 (2022) 102113
identity or expression, and includes expectations of rejection or participant- and study-level variables impact the observed relationships
discrimination based on TGD identity, concealment of one's TGD iden between TGD minority stress and mental health outcomes. Therefore,
tity, and internalized transphobia or TGD-related self-stigma. the objective of the current study is to systematically review and meta-
Experiences of distal minority stress are relatively common among analyze quantitative research that examines the relationship between
TGD individuals. This population experiences disproportionate rates of minority stress constructs and depression, suicidal ideation, and suicide
violence victimization compared to their cisgender peers, and these attempt in TGD individuals.
experiences of violence are associated with disproportionate rates of
mental health problems (Grant et al., 2011; Stotzer, 2009). Much of this 1. Method
violence likely results from others' perception or knowledge of their TGD
identity, making it fall under the umbrella of distal stress. For example, The current meta-analysis follows PRISMA reporting guidelines for
asking to be treated according to their gender identity (e.g., through use meta-analyses (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group,
of pronouns and name) significantly predicts violence victimization 2009) and was pre-registered in PROSPERO (ID# CRD42020185063)
(Domínguez-Martínez et al., 2020). Likewise, gender nonconformity is before systematic searches, data extraction, and analyses were
also associated with greater levels of violent victimization among TGD performed.
people (Miller & Grollman, 2015). These experiences of overt victimi
zation are not unique to adults; TGD youth also experience higher rates 1.1. Search strategy
of in-person and online bullying compared to their cisgender peers
(Abreu & Kenny, 2018; Reisner, Greytak, Parsons, & Ybarra, 2015; Boolean operators were used to combine search terms related to TGD
Ybarra, Mitchell, & Kosciw, 2014). identity, minority stress processes, depression, and suicidality. TGD-
Distal stress encompasses not only overt violence and victimization, related keywords were derived from a previous systematic review of
but also more institutional and environmental forms of discrimination search terms related to TGD populations (Lee, Ylioja, & Lackey, 2016).
against TGD individuals. TGD adults experience discrimination in Using the EBSCOhost interface, searches of the PsycINFO, MEDLINE,
housing and employment at significantly higher rates compared to even and LGBT Life databases were conducted for records published between
their sexual minority peers (Kattari, Whitfield, Walls, Langenderfer- January 1, 2000 and June 1, 2021. The search string can be seen in
Magruder, & Ramos, 2016). These experiences can range from denial Appendix A.
or termination of employment and hostile work environment (Brewster,
Velez, Mennicke, & Tebbe, 2014; Budge, Tebbe, & Howard, 2010; Dis 1.2. Eligibility criteria
penza, Watson, Chung, & Brack, 2012), to denial of access to housing
and eviction (Esses, 2008). Inclusion criteria sought to restrict included records to quantitative
Furthermore, despite their particular physical health needs (e.g., research that reports effect sizes for the relationship between minority
gender-affirming medical interventions), TGD people frequently stress constructs and depression or suicidality in TGD samples. To be
encounter distal stressors in healthcare settings, in the form of non- included, studies must have satisfied the following inclusion criteria: (1)
affirmation from providers, lack of competence or knowledge in published in English; (2) sample consists entirely of TGD participants or
gender-affirming care, and denial of gender-affirming care by insurance provides effect size(s) for TGD subsamples; (3) contains at least one
providers (Cicero, Reisner, Silva, Merwin, & Humphreys, 2019; Roma measure of minority stress (i.e., internalized transphobia, concealment/
nelli & Lindsey, 2020). These barriers to gender-affirming care have disclosure, expectations of rejection, or distal stress); (4) contains at
significant implications for TGD mental health; although medical tran least one measure of depression (e.g., binary diagnosis, rating scale of
sition is associated with improved mental health outcomes (Achille depressive symptoms), suicidal ideation, or suicide attempt; and (5)
et al., 2020; Bränström & Pachankis, 2020; White Hughto & Reisner, reported an effect size for the relationship between measures of minority
2016), many TGD individuals delay care due to fear of discrimination stress and depression, suicidal ideation, or suicide attempt. In order to
from healthcare providers (Glick, Theall, Andrinopoulos, & Kendall, restrict included articles to those examining TGD populations in isola
2018; Seelman, Colón-Diaz, LeCroix, Xavier-Brier, & Kattari, 2017). tion, studies were excluded if they only reported effect sizes for com
Proximal forms of minority stress also play an important role in the bined sexual minority and TGD samples. Furthermore, since HIV stigma
mental health and well-being of TGD persons. Many TGD individuals processes mirror those of gender-related minority stress (e.g., both
frequently internalize negative societal messages and attitudes towards include internalized stigma; Earnshaw & Chaudoir, 2009; Earnshaw,
those who identify as TGD, which often leads to feelings of emotional Smith, Chaudoir, Amico, & Copenhaver, 2013), and HIV-status is
distress and negative self-perception (Rood, Reisner, et al., 2017b). They significantly associated with the outcomes of interest (e.g., Ciesla &
also often expect rejection from others in a variety of social settings, and Roberts, 2001; Pelton et al., 2021), studies were excluded if their sample
this hypervigilance can lead to feelings of exhaustion, fear, and self- consisted entirely of HIV+ individuals. For studies in which minority
loathing (Rood et al., 2016). Finally, theory suggests that proximal stress constructs and outcomes of interest were measured but insuffi
stressors serve as a mediator between distal forms of stress and poor cient information was reported to calculate an effect size (n = 53),
mental health outcomes in the TGD population (Hatzenbuehler, 2009). corresponding authors were contacted to request relevant data. Twelve
Additionally, proximal minority stress may also exacerbate the impact of of the contacted authors provided at least some of the requested infor
distal stress on mental health outcomes (e.g., Rood, Maroney et al., mation, yielding an additional 21 effect sizes to be included in the final
2017a). analyses.
Quantity of and interest in research into TGD mental health has
grown dramatically in recent years (Delli & Livas, 2021; Sweileh, 2018), 1.3. Study selection and coding
with much written about its relationship with minority stress processes.
A recent review has found consistent evidence for associations between A flow diagram showing the search and study selection processes is
TGD minority stress processes, depression, and suicidality (Valentine & displayed in Fig. 1. Database searching and screening of titles and ab
Shipherd, 2018). Nevertheless, the relative importance of each of these stracts for inclusion were conducted by the first author. The database
minority stress constructs on mental health outcomes has yet to be search yielded 1690 records (1335 after duplicates were removed), of
quantified. Existing research is equivocal as to whether poor mental which 322 were selected by the first author for full-text review. The first
health outcomes are more strongly associated with distal (e.g., Zeluf author reviewed the full-texts of selected studies for inclusion criteria,
et al., 2018) or proximal (e.g., Testa, Habarth, Peta, Balsam, & Bockting, and the second author reviewed 25% of the full-text articles, with dis
2015) minority stress constructs. It is also unclear the extent to which agreements resolved through discussion.
2
Fig. 1. PRISMA flowchart.
3
All studies that met inclusion criteria (n = 85) were then indepen published doctoral dissertations and masters' theses to reduce the po
dently coded by the first author and 25% of those studies were re-coded tential for publication bias. Furthermore, the potential effect of publi
by the second author, with disagreements resolved through discussion. cation bias on results was assessed in two ways: funnel plots and fail-safe
Effect sizes for the relationship between minority stress, depression, and N.
suicidality were extracted, along with the specific scales that were used Funnel plots, which plot study effect sizes against their standard
to measure these constructs. The following moderator variables were error (Sterne, Becker, & Egger, 2005), were visually inspected for
also extracted from each of the included studies: sample size, study asymmetry (an indicator of publication bias). In addition, due to the
design, country, mean age of sample, proportion of sample assigned fallibility of visual identification of publication bias in funnel plots
female at birth, proportion of sample identified as non-White, and pro (Terrin, Schmid, & Lau, 2005), Egger's regression test (Egger, Smith,
portion of sample identified as a sexual minority. Schneider, & Minder, 1997) was used to statistically test for the presence
of significant funnel plot asymmetry. Fail-safe N can be defined as the
1.4. Analytic plan hypothetical number of studies with null findings that, when added to
the pooled effect size, would make the overall z-test non-significant
All analyses were conducted in R version 4.0.5 (R Core Team, 2021) (Orwin, 1983; Rosenthal, 1979). This value has been characterized as
and RStudio 1.4.1106 (RStudio Team, 2021) using the “meta” (Balduzzi, a useful method of evaluating the stability of the results of a meta-
Rücker, & Schwarzer, 2019) and “metafor” packages (Viechtbauer, analysis if new, null results were later found (Carson, Schriesheim, &
2010). Twelve pooled effect sizes were estimated to assess the strength Kinicki, 1990). For α = 0.05, the following formula was used to calculate
of the relationship between minority stress constructs (i.e., distal stress, fail-safe n:
internalized transphobia, expectations of rejection, and concealment) [ ]
Nfs = (k/2.706) k(Zk )2 –2.706
and mental health outcomes (i.e., depression, suicidal ideation, and
suicide attempt). Following the methods outlined by Borenstein, Hed
where k is the number of studies and Zk is the mean Z obtained for the k
ges, Higgins, and Rothstein (2009), all effect sizes were converted to
studies” (Rosenthal, 1979, p. 639). Rosenthal (1979) suggests that effect
correlation coefficients. In studies where only standardized regression
sizes are resistant to the effect of publication bias (the file-drawer effect)
coefficients were reported, these effect sizes were converted to corre
if Nfs > 5 k + 10, and this rule of thumb was used for the current meta-
lation coefficients using the imputation formula specified by Peterson
analysis.
and Brown (2005). In studies where only a chi-square value was re
ported, those effect sizes were converted to correlation coefficients using
the formula specified by Rosenberg (2010). When a study reported 1.6. Study quality assessment
multiple effect sizes for distal stress (e.g., separately for victimization
and discrimination), the mean of these effect sizes was used. Fisher's r- Individual study quality was assessed by the first author using the
to-z transformation was conducted on correlation coefficient effect sizes Appraisal Tool for Cross-Sectional Studies (AXIS; Downes, Brennan,
in order to reduce Type I error rates (Alexander, Scozzaro, & Borodkin, Williams, & Dean, 2016). This tool consists of 20 items that assess
1989). Where the article text stated that a relationship between minority various facets of the studies' methodological and reporting quality,
stress and outcome variables of interest was non-significant, but no including clarity of study methods, representativeness of the study
numerical effect size was reported, an effect size of r = 0 was imputed. sample, likelihood of sampling and selection bias, and appropriateness
Measures of heterogeneity were used to determine the consistency of of study variables and measures. Each study included in the current
the effect sizes across studies for each predictor and outcome variable meta-analysis was assigned a rating for each of the 20 AXIS items: yes
pair. Two statistical methods were used in the current meta-analysis to (+), no (− ), or unknown/insufficient information (?).
quantify between-study variability: Q and I2. Q is a statistical test that
determines the presence or absence of significant heterogeneity (i.e., if Q 2. Results
is significant, there is significant between-study heterogeneity), whereas
I2 determines the degree of between-study heterogeneity in effect sizes 2.1. Description of studies
(Huedo-Medina, Sánchez-Meca, Marín-Martínez, & Botella, 2006). I2
values of 25%, 50%, and 75% indicate low, medium, and high levels of A total of 85 studies were included in the current meta-analysis,
heterogeneity respectively (Higgins, Thompson, Deeks, & Altman, yielding 159 effect sizes for the relationship between minority stress
2003). Given that heterogeneity is typically expected in meta-analyses and mental health constructs. Included studies are listed in Appendix B.
(Higgins, 2008), a random-effects model was used for the current Included studies were published between 2006 and 2021, with a median
meta-analysis since it does not assume an identical true effect size across publication year of 2018. Sample sizes of TGD participants ranged
studies (Borenstein, Hedges, Higgins, & Rothstein, 2010). widely from 6 to 5584 (M = 502.38, SD = 924.96). Regarding sample
In order to ensure adequate power to conduct moderator analyses, a location, 59 of the included studies (69.41%) recruited their samples
minimum of 10 studies per study-level moderator variable was used primarily from the United States and/or Canada. All of the effect sizes
(Deeks, Higgins, & Altman, 2019; Fu et al., 2011). For those minority included in the current meta-analysis examined the cross-sectional
stress/mental health variable pairs with k ≥ 10, moderator analyses relationship between minority stress and mental health constructs.
were conducted for each moderator variable individually. If multiple
moderator variables were found to be significant, and there were an 2.2. Preliminary analyses
adequate number of included studies (i.e., at least 10 per significant
moderator), all significant moderator variables were entered together Heterogeneity. Observation of substantial heterogeneity provided
into a meta-regression predicting effect size. support for the use of a random-effects model over a fixed-effects model.
Significant Q-tests of homogeneity were found for the relationship be
1.5. Publication bias tween depression and distal stress (Q(55) = 547.21, p < .001), inter
nalized transphobia (Q(15) = 109.87, p < .001), expectations of
Deliberate steps were taken to prevent and detect the potential effect rejection (Q(10) = 35.79, p < .001), and concealment (Q(9) = 26.57, p
of publication bias on the results of the current meta-analysis. Since = .002). Significant heterogeneity was also observed for the association
graduate theses often remain unpublished if they do not contain sig between suicidal ideation and distal stress (Q(27) = 299.45, p < .001)
nificant results (Easterbrook, Berlin, Gopalan, & Matthews, 1991), the and internalized transphobia (Q(5) = 64.02, p < .001), but not expec
inclusion criteria for the current meta-analysis allowed for non- tations of rejection (Q(2) = 5.28, p = .071), and concealment (Q(1) =
4
1.31, p = .253). Lastly, significant heterogeneity was observed for as effect sizes were significantly moderated by study-level variables (i.e.,
sociations between suicide attempt and distal stress (Q(19) = 229.67, p sample size, year of publication, country, mean age, % assigned female
< .001) and internalized transphobia (Q(3) = 10.70, p = .013), but not at birth, % sexual minority, % non-White). Moderator analyses were
expectations of rejection (Q(1) = 0.43, p = .513). Due to an insufficient only conducted for minority stress-mental health pairs for which k ≥ 10.
number of studies (k = 1), Q could not be calculated for the relationship Since the majority of included studies consisted of samples from the
between suicide attempt and concealment. United States and/or Canada, the country variable was dichotomized as
Further evidence for significant heterogeneity is provided by high I2 US/Canada vs. non-US/Canada for moderator analyses.
values. Based on the interpretations of I2 proposed by Higgins et al. When moderators were entered individually, effect sizes for the
(2003), high levels of heterogeneity among effect sizes were observed relationship between distal stress and suicidal ideation were signifi
for the relationship between depression and distal stress (I2 = 89.9), cantly moderated by the proportion of the sample that identifies as a
internalized transphobia (I2 = 86.3), expectations of rejection (I2 = sexual minority (z = − 2.208, p = .026, R2 = 0.412, k = 12) and pro
72.1), and concealment (I2 = 66.1). Heterogeneity was also high for the portion of the sample that identifies as non-White (z = 3.354, p < .001,
relationship between suicidal ideation and distal stress (I2 = 91.0), R2 = 0.530, k = 19). These effects were such that the relationship be
internalized transphobia (I2 = 92.2), and expectations of rejection (I2 = tween distal stress and suicidal ideation was weaker in samples with
62.1), but low for concealment (I2 = 23.6). Finally, heterogeneity was greater proportions of sexual minorities and stronger in samples with
high for the relationship between suicide attempt and distal stress (I2 = greater proportions of non-White participants. When these moderators
91.7) and internalized transphobia (I2 = 72.0), but low for expectations were entered together, they accounted for 54.33% of the variance in
of rejection (I2 = 0.00). As with Q, I2 could not be calculated for the effect size. Only the proportion of the sample that identifies as a sexual
relationship between suicide attempt and concealment due to an minority remained significant (z = − 2.127, p = .033, k = 11). No sig
insufficient number of studies. nificant moderators were found for the relationship between distal stress
and depression and suicide attempt.
Regarding proximal stress constructs, when moderators were entered
2.3. Main analyses individually, effect sizes for the relationship between concealment and
depression were significantly moderated by proportion of the sample
Bivariate summary effect sizes. Main analyses examining the rela that identifies as a sexual minority (z = 1.843, p = .065, R2 = 1.000, k =
tionship between mental health and minority stress constructs are dis 4). No significant moderators were found for the relationship between
played in Table 1. Significant pooled effect sizes were observed for depression and internalized transphobia or expectations of rejection.
associations between depression and proximal minority stress variables,
including internalized transphobia (r = 0.33, 95% CI [0.24, 0.40], k =
2.4. Publication bias
16), expectations of rejection (r = 0.35, 95% CI [0.28, 0.41], k = 11),
and concealment (r = 0.22, 95% CI [0.15, 0.29], k = 10). Similar results
The funnel plot for studies assessing the relationship between distal
were found for the association between depression and distal minority
stress and depression is displayed in Fig. 2. Egger's test for funnel plot
stress (r = 0.26, 95% CI [0.22, 0.30], k = 56). With suicidal ideation as
asymmetry found that there was no significant asymmetry for any of the
the outcome of interest, significant pooled effect sizes were found for
minority stress-outcome pairs with ≥10 (all p > .05).
distal stress (r = 0.24, 95% CI [0.19, 0.29], k = 28), internalized
All but one of the minority stress-mental health pairs had fail-safe n
transphobia (r = 0.29, 95% CI [0.13, 0.43], k = 6), expectations of
values that exceeded the cutoff defined by Rosenthal (1979). Thus, with
rejection (r = 0.30, 95% CI [0.23, 0.38], k = 3), and concealment (r =
the exception of the association between internalized transphobia and
0.17, 95% CI [0.08, 0.25], k = 2). Finally, significant pooled correlations
suicide attempt (Nfs = 18, 5 k + 10 = 30), relationships between mi
were found for the relationship between suicide attempt and distal stress
nority stress and mental health outcomes appeared robust to publication
(r = 0.21, 95% CI [0.15, 0.26], k = 20) and expectations of rejection (r =
bias. There was an insufficient number of studies examining the asso
0.15, 95% CI [0.09, 0.21], k = 2), but the pooled correlation between
ciation between concealment and suicide attempt (k = 1) to calculate a
suicide attempt and internalized transphobia was only marginally sig
fail-safe n for that relationship.
nificant (r = 0.09, 95% CI [0.00, 0.18], k = 4). There was an insufficient
number studies to calculate a pooled effect size for the relationship
between suicide attempt and concealment, but the one included study 2.5. Study quality assessment
that examined this relationship (Cogan, Scholl, Cole, & Davis, 2020)
found that the association was not significant (r = − 0.01, 95% CI AXIS ratings for studies included in the current meta-analysis are
[− 0.16, 0.15]). presented in Table C1. A number of common limitations can be identi
Moderator analyses. Meta-regression was used to determine whether fied from these ratings. With very few exceptions (e.g., Vance, Boyer,
Table 1
Pooled effect sizes and measures of heterogeneity for relationships between minority stress and mental health constructs.
Predictor Outcome k n Effect size Heterogeneity
r [95% CI] z p I2 Q p
Distal Depression 56 25,466 0.26 [0.22, 0.30] 11.78 < 0.001 89.9 547.21 < 0.001
IT Depression 16 5014 0.33 [0.24, 0.40] 7.34 < 0.001 86.3 109.87 < 0.001
ER Depression 11 3836 0.35 [0.28, 0.41] 9.19 < 0.001 72.1 35.79 < 0.001
Concealment Depression 10 3863 0.22 [0.15, 0.29] 6.34 < 0.001 66.1 26.57 0.002
Distal SI 28 19,615 0.24 [0.19, 0.29] 8.63 < 0.001 91.0 299.45 < 0.001
IT SI 6 1972 0.29 [0.13, 0.43] 3.49 < 0.001 92.2 64.02 < 0.001
ER SI 3 1767 0.30 [0.23, 0.38] 7.52 < 0.001 62.1 5.28 0.071
Concealment SI 2 971 0.17 [0.08, 0.25] 3.91 < 0.001 23.6 1.31 0.253
Distal SA 20 20,991 0.21 [0.15, 0.26] 7.47 < 0.001 91.7 229.67 < 0.001
IT SA 4 2238 0.09 [0.00, 0.18] 1.94 0.052 72.0 10.70 0.013
ER SA 2 951 0.15 [0.09, 0.21] 4.61 < 0.001 0.00 0.43 0.513
Concealment SA 1 155 − 0.01 [− 0.16, 0.15] – – – – –
Note. CI = confidence interval; ER = expectations of rejection; ES = effect size; IT = internalized transphobia; SA = suicide attempt; SI = suicidal ideation.
5
Fig. 2. Funnel plot for studies assessing the relationship between distal stress and depression.
Glidden, & Sevelius, 2021), the vast majority of studies used conve sensitivity) are more likely to negatively appraise social interactions,
nience sampling techniques rather than utilizing population-based which leads to an increased likelihood of depression (Gao, Assink,
samples. Likewise, few studies provided information on non- Cipriani, & Lin, 2017; Normansell & Wisco, 2017). Although discrete
responders, leaving them potentially susceptible to non-response bias. rejection experiences may not lead to significantly lower affect in
themselves (Blackhart, Nelson, Knowles, & Baumeister, 2009), over time
3. Discussion they can prompt an individual to appraise situations more negatively
(Mehu & Scherer, 2015). Thus, it is thought that the effects of external
The current study sought to systematically review and meta-analyze situations (i.e., distal stress) on mental health are largely mediated by
existing research examining the relationship between minority stress internal processes (i.e., proximal stress). As a consequence, such models
constructs, depression, suicidal ideation, and suicide attempt in trans imply that the effect of distal stress processes on mental health outcomes
gender and gender diverse (TGD) individuals. Significant bivariate as would generally be smaller than those of proximal stress processes. It is
sociations were found between all minority stress constructs (i.e., distal not the experience of rejection itself, but rather, the appraisal of rejection
stress, internalized transphobia, expectations of rejection, and conceal experiences that determines an individual's affective response to in
ment) and depression, suicidal ideation, and suicide attempt. For stances of rejection. For those that identify as TGD, this would suggest
depression and suicidal ideation, effect sizes in the current meta-analysis that expectations of rejection are more strongly associated with
appear to be larger for expectations of rejection and internalized depression and suicide than experiencing status-based rejection itself,
transphobia when compared to distal stress and concealment. These and this conclusion is supported by the findings of the current meta-
results provide evidence in support of the minority stress model for TGD analysis.
individuals (Hendricks & Testa, 2012; Meyer, 2003), namely that higher Internalized transphobia may function similarly to expectations of
levels of both distal and proximal minority stress are associated with rejection within the minority stress framework. Negative views of the
higher levels of depression and suicidality. Yet, all of the effect sizes that self are strongly associated with poor mental health outcomes in the
were included in the current meta-analysis were for cross-sectional as general population. For example, low self-esteem significantly predicts
sociations, which are limited in their ability to draw causal inferences. depression (Sowislo & Orth, 2013) and viewing oneself as a burden to
The small amount of longitudinal research that exists in this area sug others predicts suicidality (Chu et al., 2018; Forkmann et al., 2020).
gests that higher levels of distal stress predict future suicidal ideation Applied to marginalized groups, negative views of one's own margin
(Rabasco & Andover, 2021), and both distal and proximal minority alized identity can mediate the relationship between identity-based
stress predict future depressive symptoms (Lloyd, Chalklin, & Bond, prejudice events and negative mental health outcomes. Such a role of
2019). Further research is needed, however, to determine the relative identity-based self-stigma in this relationship has been observed in a
longitudinal effects of different minority stress processes on mental variety of marginalized groups, including people with mental illnesses
health outcomes in TGD individuals. (Kao et al., 2016; Oexle, Waldmann, Staiger, Xu, & Rüsch, 2018; Picco
The observed greater magnitude of effect sizes for expectations of et al., 2017), people with obesity (Hayward, Vartanian, & Pinkus, 2018;
rejection may be theoretically explained through appraisal theory, Sikorski, Luppa, Luck, & Riedel-Heller, 2015), sexual minorities (Fein
which proposes that a person's evaluation of a situation, rather than the stein, Goldfried, & Davila, 2012; Hatzenbuehler, 2009; Walch, Nga
situation itself, determines their emotional and affective response to the make, Bovornusvakool, & Walker, 2016), and racial/ethnic minorities
situation (Moors, Ellsworth, Scherer, & Frijda, 2013; Scherer, 1999). (Graham, West, Martinez, & Roemer, 2016; Sosoo, Bernard, & Neblett,
Negative cognitive appraisals have also been theorized to serve as a 2020). This research suggests that the impact of distal stress on mental
mediator between stressful life events and depression (Mehu & Scherer, health depends on internalized stigma, which could explain the greater
2015) and suicide (Schematic Appraisal Model of Suicide; Johnson, effect size for internalized transphobia in the current meta-analysis.
Gooding, & Tarrier, 2008). In the context of interpersonal interactions, Unlike internalized transphobia and expectations of rejection,
those who anticipate rejection from others (i.e., have high rejection concealment had a lower observed effect size in the current meta-
6
analysis compared to distal stress. Concealment plays a unique role not engaged in sex work (Logie et al., 2017). Nevertheless, many of the
within minority stress theory, and the observed lower effect sizes for studies that utilized these specific populations did not differ substan
concealment may be potentially explained by the complex relationship tially from the pooled effect sizes that were observed (e.g., Carter et al.,
this construct has with mental health outcomes. Concealing a stigma 2019, r = 0.25 for suicidal ideation and distal stress; for Nemoto et al.,
tized identity undoubtedly can be cognitively and affectively taxing 2011, r = 0.31 for depression and distal stress). Additional research
(Brennan et al., 2021; Pachankis, 2007), and disclosing a stigmatized could help provide insight into how minority stress affects specific
identity can lead to positive mental health outcomes (Camacho, Reinka, subpopulations that may experience additional identity-based stressors.
& Quinn, 2020). Yet, disclosures can have negative consequences when Studies also differ in their countries of origin, which may further
there is a negative response from others (Chaudoir & Fisher, 2010). As a contribute to heterogeneity across studies. Countries range in terms of
result, individual decisions on whether to conceal one's transgender their attitudes towards TGD communities (Elischberger, Glazier, Hill, &
identity are highly dependent on social context, and frequently require Verduzco-Baker, 2018; Worthen, Lingiardi, & Caristo, 2017) and rights
balancing authentic self-expression with considerations of safety and (Earle, Hoffarth, Prusaczyk, MacInnis, & Hodson, 2021). As a result,
negative disclosure reactions (Brumbaugh-Johnson & Hull, 2019; Fer TGD people may experience more minority stress in countries compared
nandez & Birnholtz, 2019; Lev, 2004). Decision-making regarding to others. Although cross-cultural research on minority stress in TGD
concealment and disclosure of TGD identity is particularly important populations is limited, sexual minority populations exhibit significant
within the healthcare context, since practitioners serve as gatekeepers to cross-cultural differences in experiences of minority stress (Baiocco
gender-affirming medical interventions within current standards of care et al., 2021; Sattler & Lemke, 2019). Although country of origin (USA/
(Ashley, 2019; Coleman et al., 2011). Concerns related to provider re CA vs. non-USA/CA) did not significantly moderate pooled effect sizes in
actions to disclosure, knowledge of and competence in TGD issues, and the current meta-analysis, the majority of included studies (69.41%)
impact of disclosure on quality of care pervade this decision-making used samples from the United States and Canada. These results indicate
process and frequently lead to stress in this population (Friley & Ven that further research is needed to examine whether there are cross-
etis, 2021). cultural differences in the impact of minority stress on depression in
Of note is the finding that the relationship between distal stress and TGD populations.
suicidal ideation (SI) was significantly moderated by proportion of the Lastly, studies were also heterogeneous in their measurement of
sample that is non-White, such that distal stress was more strongly variables of interest. Whereas some studies used continuous measures of
associated with SI in studies with a greater proportion of non-White TGD minority stress with psychometric support (e.g., Gender Minority
participants. This finding could reflect the additive and intersectional Stress and Resilience Measure; Testa et al., 2015), others used dichoto
nature of minority stress of individuals with multiple marginalized mous single-item measures. Similar differences in measurement were
identities. For example, sexual minority people of color experience observed for measures of depression and suicidality. Dichotomous
discrimination based on their combined racial/ethnic and sexual mi measures have lower reliability and validity compared to continuous
nority identities (Balsam, Molina, Beadnell, Simoni, & Walters, 2011; measures (e.g., Markon, Chmielewski, & Miller, 2011), and studies that
Cyrus, 2017; McConnell, Janulis, Phillips, Truong, & Birkett, 2018; utilize the former may report attenuated correlations due to measure
Ramirez & Galupo, 2019; Sarno, Swann, Newcomb, & Whitton, 2021), ment unreliability. Future research on TGD minority stress would
which may account for their disproportionately high rates of depression benefit from using empirically-validated and psychometrically strong
and suicidality (Kimball, Bonds, Brady, & Blashill, 2021; Vargas, Huey, measures of minority stress and mental health variables.
& Miranda, 2020). TGD people of color may likewise experience mul
tiple intersecting forms of minority stress that contribute to their 3.1. Limitations
disproportionate rates of poor mental health outcomes (Farvid et al.,
2021). Nevertheless, research examining multiple minority stressors in The results of this meta-analysis should be interpreted in light of its
TGD people of color is extremely limited, and future research should limitations. Substantial heterogeneity in effect sizes was observed across
prioritize this particularly vulnerable sub-population. many of the relationships between minority stress and mental health
Significant between-study heterogeneity was observed in the effect outcomes, which may reflect between-study heterogeneity in the con
size estimates of the current meta-analysis, which may be explained by a structs being measured. The construct of distal stress in the current
number of factors. First, the complex relationship between concealment meta-analysis represents a wide array of prejudice events, from minor
of gender identity and mental health (as described above) may have led experiences of transphobia (e.g., transgender-related microaggressions;
to heterogeneity in observed effect sizes across studies. Second, studies Austin, Craig, D’Souza, & McInroy, 2020) to physical violence (e.g.,
varied widely in terms of their sampling frame, and gender minority Barboza, Dominguez, & Chace, 2016) and sexual victimization (e.g.
stress may interact with other forms of minority stress within certain Scandurra, Amodeo, Bochicchio, Valerio, & Frost, 2017). Researchers
subpopulations of TGD individuals. Third, studies came from a wide that have examined the relative effects of different types of distal stress
variety of countries, which may differ widely in their attitudes and on psychological outcomes have found that some types of distal stress
treatment towards TGD populations. Finally, differences in measure lead to worse psychological outcomes than others, with non-affirmation
ment of minority stress and mental health (e.g., multi-item scale vs. of gender identity being more strongly associated with depression and
single dichotomous item) may have led to heterogeneity of effect sizes suicidality than gender-related victimization, rejection, or discrimina
across studies. tion (Cogan et al., 2020; Hidalgo, Petras, Chen, & Chodzen, 2019; Jäggi
Between-study heterogeneity may be accounted for by notable dif et al., 2018; Scandurra et al., 2020; Tebbe, Allan, & Bell, 2019; Testa
ferences in study samples used. Many of the studies included in the et al., 2015, 2017). Similarly, although the current meta-analysis
present analyses sampled from specific sub-populations of TGD in conceptualized gender identity concealment as a unitary construct,
dividuals, such as TGD veterans (Beckman, Shipherd, Simpson, & concealment in TGD populations may be a multi-faceted construct that
Lehavot, 2018; Carter et al., 2019; Ruben, Livingston, Berke, Matza, & includes lack of active disclosure, lack of general openness, and lack of
Shipherd, 2019; Tucker et al., 2019), and TGD individuals with a history public knowledge of a person's TGD identity (Pachankis, Jackson,
of sex work (Nemoto, Bödeker, & Iwamoto, 2011; She, 2019). It's Fetzner, Mahon, & Bränström, 2021).
possible that TGD minority stress may operate differently in these Furthermore, some researchers have theorized that the current
populations due to unique stressors related to the sub-population. For conceptualization of gender minority stress does not encompass the
instance, transgender sex workers are significantly more likely to range of gender-related stressors experienced by those who identify as
experience violence victimization and forced sex compared to cisgender TGD. Gender dysphoria, for example, has been proposed as an additional
sex workers (Miller et al., 2020) and transgender individuals who have proximal stressor that current minority stress theory fails to include
7
(Lindley & Galupo, 2020). Gender minority stress may also interact with American Psychological Association. (2015). Guidelines for psychological practice with
transgender and gender nonconforming people. American Psychologist, 70(9),
other forms of discrimination (e.g., racism) to create additive forms of
832–864. https://doi.org/10.1037/a0039906
stress that cannot be captured by looking at each marginalized identity Ashley, F. (2019). Gatekeeping hormone replacement therapy for transgender patients is
in isolation (Tan, Treharne, Ellis, Schmidt, & Veale, 2020). Regardless of dehumanising. Journal of Medical Ethics, 45(7), 480–482. https://doi.org/10.1136/
these aforementioned limitations, the current meta-analysis provides medethics-2018-105293
Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy:
robust evidence for the relationship between minority stress, depression, Clinical considerations and applications. Professional Psychology: Research and
and suicidality. Practice, 46(1), 21–29. https://doi.org/10.1037/a0038642
Austin, A., Craig, S. L., D’Souza, S., & McInroy, L. B. (2020). Suicidality among
transgender youth: Elucidating the role of interpersonal risk factors. Journal of
3.2. Clinical implications Interpersonal Violence. https://doi.org/10.1177/0886260520915554. Advance
online publication.
Baiocco, R., Scandurra, C., Rosati, F., Pistella, J., Ioverno, S., Bochicchio, V.Chang, T., …
Finally, the present meta-analysis has important clinical implica (2021). Minority stress, resilience, and health in italian and taiwanese LGB+ people:
tions. Significant associations between minority stress and mental health A cross-cultural comparison. Current Psychology. https://doi.org/10.1007/s12144-
021-01387-2. Advance online publication.
outcomes in the current study bolster existing clinical practice guide
Balduzzi, S., Rücker, G., & Schwarzer, G. (2019). How to perform a meta-analysis with R:
lines that incorporate minority stress theory in work with TGD clients (e. A practical tutorial. Evidence-Based Mental Health, 22(4), 153–160. https://doi.org/
g., Austin & Craig, 2015; Brewster, Motulsky, & Glaeser, 2019; Puckett 10.1136/ebmental-2019-300117
& Levitt, 2015). In particular, the larger observed effect sizes for ex Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring
multiple minority stress: The LGBT people of color microaggressions scale. Cultural
pectations of rejection and internalized transphobia implicate these Diversity and Ethnic Minority Psychology, 17(2), 163–174. https://doi.org/10.1037/
constructs as essential points of intervention for clinical psychologists. a0023244
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identity and suicide risk among transgender men and women. Preventive Medicine
minority stress in sexual minority populations (see Chaudoir, Wang, & Reports, 4, 385–390. https://doi.org/10.1016/j.pmedr.2016.08.003
Pachankis, 2017 for a review), comparable research is limited for TGD Beckman, K., Shipherd, J., Simpson, T., & Lehavot, K. (2018). Military sexual assault in
populations. Future research should focus on assessing the efficacy of transgender veterans: Results from a nationwide survey. Journal of Traumatic Stress,
31(2), 181–190. https://doi.org/10.1002/jts.22280
interventions for TGD populations that focus on proximal minority stress Blackhart, G. C., Nelson, B. C., Knowles, M. L., & Baumeister, R. F. (2009). Rejection
as a point of intervention. Additionally, moderation analyses suggest elicits emotional reactions but neither causes immediate distress nor lowers self-
that TGD people of color are particularly vulnerable to the insidious esteem: A meta-analytic review of 192 studies on social exclusion. Personality and
Social Psychology Review, 13(4), 269–309. https://doi.org/10.1177/
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rating an intersectional lens into their practice to aid clients in coping meta-analysis. Hoboken, NJ: John Wiley & Sons. https://doi.org/10.1002/
with such unique forms of minority stress (Golden & Oransky, 2019; 9780470743386
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2010). A basic
Malpas, Pellicane, & Glaeser, 2021). introduction to fixed-effect and random-effects models for meta-analysis. Research
Synthesis Methods, 1(2), 97–111. https://doi.org/10.1002/jrsm.12
Borgogna, N. C., McDermott, R. C., Aita, S. L., & Kridel, M. M. (2019). Anxiety and
Role of funding sources
depression across gender and sexual minorities: Implications for transgender, gender
nonconforming, pansexual, demisexual, asexual, queer, and questioning indivdiuals.
The authors received no external funding for the current manuscript. Psychology of Sexual Orientation and Gender Diversity, 6(1), 54–63. https://doi.org/
10.1037/sgd0000306
Bränström, R., & Pachankis, J. E. (2020). Reduction in mental health treatment
Contributors utilization among transgender individuals after gender-affirming surgeries: A total
population study. American Journal of Psychiatry, 177(8), 727–734. https://doi.org/
10.1176/appi.ajp.2019.19010080
Michael Pellicane and Jeffrey Ciesla designed the study. Michael
Brennan, J. M., Dunham, K. J., Bowlen, M., Davis, K., Ji, G., & Cochran, B. N. (2021).
Pellicane conducted literature searches. Michael Pellicane and Jeffery Inconcealable: A cognitive-behavioral model of concealment of gender and sexual
Ciesla conducted statistical analyses. Michael Pellicane wrote the first identity and associations with physical and mental health. Psychology of Sexual
draft of the manuscript. Michael Pellicane and Jeffrey Ciesla reviewed Orientation and Gender Diversity, 8(1), 80–93. https://doi.org/10.1037/sgd0000424
Brewster, M. E., Motulsky, W., & Glaeser, E. (2019). Working with gender-expansive
and edited the manuscript. All authors contributed to and have clients in psychotherapy. Journal of Clinical Psychology, 75, 1993–2005. https://doi.
approved the final manuscript. org/10.1002/jclp.22859
Brewster, M. E., Velez, B. L., Mennicke, A., & Tebbe, E. (2014). Voices from beyond:
Content analysis of transgender employees’ workplace experiences. Psychology of
Declaration of Competing Interest Sexual Orientation and Gender Diversity, 1(2), 159–169. https://doi.org/10.1037/
sgd0000030
Brumbaugh-Johnson, S. M., & Hull, K. E. (2019). Coming out as transgender: Navigating
All authors declare that they have no conflicts of interest. the social implications of a transgender identity. Journal of Homosexuality, 66(8),
1148–1177. https://doi.org/10.1080/00918369.2018.1493253
Budge, S. L., Tebbe, E. N., & Howard, K. A. S. (2010). The work experiences of
Appendix A. Supplementary data transgender individuals: Negotiating the transition and career decision-making
processes. Journal of Counseling Psychology, 57(4), 377–393. https://doi.org/
Supplementary data to this article can be found online at https://doi. 10.1037/a0020472
Camacho, G., Reinka, M. A., & Quinn, D. M. (2020). Disclosure and concealment of
org/10.1016/j.cpr.2021.102113.
stigmatized identities. Current Opinion in Psychology, 31, 28–32. https://doi.org/
10.1016/j.copsyc.2019.07.031
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Associations between minority stress, depression, and suicidal ideation and

Fig. 1. PRISMA flowchart.

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