Marginalized populations, such as people who identify as transgender and gender diverse (TGD), carry a disproportionately high burden of mental disorders, compared with the general population. It is well documented that TGD people are more likely to face trauma and adversity including physical attacks, verbal abuse, stigma, and discrimination compared with cisgender people. Although there are studies reporting on mental disorders in the TGD population, there are few large population-based studies that compare the TGD population with the cisgender population using a validated diagnostic tool. The objectives of this study were to investigate the prevalence and risk of mental disorders, substance use disorders, and suicidal behaviors (both past 12 months and lifetime) in a population-representative sample of TGD and cisgender Canadians.
This study uses data from the Mental Health and Access to Care Survey (MHACS), which is a nationally representative cross-sectional study administered by Statistics Canada from March to July 2022. Statistics Canada obtained informed consent from all participants; ethical approval for this specific analysis was not required. The STROBE reporting guideline was followed.
There was a 25% response rate, resulting in a sample size of 9861 people. When sex at birth and gender identity matched, respondents were classified as cisgender; in the case of a mismatch, respondents were classified as TGD. Past 12-month and lifetime major depressive episode, generalized anxiety disorder, bipolar disorder, social phobia, alcohol use disorder, and substance use disorder, suicidal thoughts, plan, and attempt were assessed as outcomes (eAppendix in Supplement 1). To ensure that the sample was representative of the Canadian population, analyses were weighted using survey and bootstrap weights provided by Statistics Canada. Modified Poisson regression with sandwich error variance estimation was used to estimate the association between gender identity and mental health outcomes. Age, household income, chronic physical illness, and racial or ethnic minority status were included in the regression model to adjust for confounding. All analysis was completed in Stata version 18 (StataCorp). Statistical significance was assessed by P < .05 and 95% CIs that did not include 1.
Of the total sample of 9861, 52 (0.53%) identified as TGD; demographic data can be found in Table 1. Past 12-month and lifetime major depressive episode, generalized anxiety disorder, bipolar disorder, social phobia, substance use disorder, suicide ideation, suicide plan, and suicide attempts were higher in TGD respondents compared with cisgender respondents (eg, lifetime prevalence of depression among cisgender: 13.7% [95% CI, 12.9%-14.6%] vs TGD: 63.7% [95% CI, 46.6%-78.0%]; adjusted rate ratio, 2.78 [95% CI, 2.16-3.57]) (Table 2). After adjusting for confounders, the risk of all 12-month and past-year mental disorders, substance use disorder, and suicide ideation were higher in TGD respondents compared with cisgender participants. The risk of lifetime suicide plan and attempts was significantly higher in TGD respondents. Alcohol use disorder did not differ between the groups (past 12 months or lifetime).
To our knowledge, this is one of the first population-based studies to find higher prevalence of mental disorders and suicidal behavior in TGD people compared with the cisgender population. This finding aligns with other studies, which have found significantly higher rates of mental health-related health service use among transgender people compared with the general population. This disparity may be explained by minority stress theory, which posits that the experience of prejudice and negative social experiences by members of historically stigmatized groups can have substantial impacts on both physical and mental health. Further research should investigate what factors lead to this and what interventions may mitigate this inequity. Limitations of this study were the small sample of TGD people and the cross-sectional nature of the study. It is also unclear whether TGD people were less likely to participate in the study compared with others. There could also be residual confounding because we were unable to include additional covariates due to sample size.
Corresponding Author: Ian Colman, PhD, School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cr, Rm 308C, Ottawa, ON K1G 5Z3, Canada ([email protected]).
Author Contributions: Dr Colman and Ms Eccles had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Critical review of the manuscript for important intellectual content: All authors.
Statistical analysis: Eccles, Ferro, Edwards.
Administrative, technical, or material support: Eccles, Elton-Marshall, Afifi.
Supervision: Elton-Marshall, Kingsbury, Colman.
Conflict of Interest Disclosures: Dr Kingsbury reported part-time employment as an analyst at Statistics Canada. No other disclosures were reported.
Funding/Support: This research was supported by the Canadian Institutes of Health Research (grant PJT 195898).
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.