- Drawing on the largest sample of transgender people ever surveyed, a new study is the first to assess the relationship between gender-concordant IDs and mental health among transgender people in the USA.
- The study finds that possessing gender-concordant IDs is associated with reduced psychological distress, and a lower prevalence of suicidal thoughts and suicide planning.
- The authors suggest policy changes to increase access to gender-concordant IDs. For example, by reducing fees, administrative hurdles and eligibility requirements, and also by either expanding gender options beyond male or female, or by removing gender markers entirely.
The authors note that the survey only questioned respondents at one time point, making it difficult to confirm whether lack of gender-affirming IDs caused psychological distress or the other way around. It is possible that trans people suffering from psychological distress might find it harder to obtain IDs. However, a previous Canadian study  found that having at least one document showing a trans person's preferred gender marker was associated with fewer suicidal thoughts and suicide attempts, and previous research has found that mental health risks in transgender adolescents are reduced when their preferred name is used socially .
"Our results suggest that governments and administrative bodies can play an important role in helping to reduce psychological distress for trans people, simply by making it easier to access identity documents that reflect their identity," says Dr Ayden Scheim from Drexel University, USA. 
Of the 1.4 million Americans who identify as transgender, over half are estimated to have clinical depression, compared to around 30% over a lifetime in the general US population, while 31% to 41% attempt suicide at some point during their lives, compared to less than 9% generally in the US. These mental health disparities can be attributed in part to a lack of recognition and acceptance of trans people's identified gender. Lack of gender-concordant official documents can prevent access to services such as healthcare, education, and employment, and increase exposure to verbal harassment and violence.
The authors suggest that at the moment, the ID change process in the USA, which varies across states, can be difficult to impossible. For example, in most US states updating a name on government-issued ID first requires a court-ordered name change, which can cost several hundred dollars. Most states require medical letters or affidavits to validate reclassification requests, and some may require gender transition surgery. In most jurisdictions, gender markers reflecting non-binary gender identity (such as an 'X' marker) are not yet available.
To explore the impact of access to IDs on psychological distress, suicidal thoughts and suicide attempts, researchers analysed data from 22,286 trans people, who were surveyed in 2015. Respondents were asked whether all, some or none of their IDs - including birth certificates, passports and driving licences - listed their preferred name and gender marker. Psychological distress was measured using a validated scale with a score between 0 and 24, with 13 or greater indicating serious psychological distress. To assess respondents' suicide risk, they were asked whether they had seriously considered suicide in the previous 12 months, whether they had made any plans to kill themselves and whether they had attempted suicide.
To ensure that the analysis was able to pick up any association between mental health and access to updated IDs, the authors of the current study adjusted the results to account for other variables that could contribute to psychological distress and suicidal thoughts - such as age, ethnicity, medical transition status and years living full-time in the identified gender.
The results found that 45.1% of respondents (10,288 out of 22,286) had no IDs with their preferred name and gender marker, 44.2% (9,666/22,286) had some ID that matched their name and/or gender, and only 10.7% (2,332/22,286) had their preferred name and gender on all their documents. The authors weighted the sample to reflect the age and ethnicity of the US population, although they note that trans demographics may not mirror broader US population demographics.
The reasons for not changing gender markers included a lack of suitable gender options (in the group with no concordant ID, people with non-binary identities were over-represented), cost, and perceived ineligibility (for example, believing that additional medical treatment was required). The authors also identified geographic variation in the results, with participants in western states more likely to have gender-concordant ID, while those in the Midwest were less likely.
Those with all gender-concordant IDs had a 32% lower prevalence of serious psychological distress than those with no updated documents. They were also 22% less likely to have had suicidal thoughts in the past year and 25% less likely to have made plans to kill themselves. Those with some updated IDs had smaller reductions in distress and suicidal thoughts (e.g., 12% reduction in distress). The results did not indicate an association between access to IDs and suicide attempts, once the authors had adjusted for other influences on mental health.
"When a trans person changes their gender on their official documents, it can be a critical step towards gaining social acceptance and legal recognition, and our findings suggest that policy changes to support trans people with taking this step should be considered, in order to help improve their wellbeing, reduce their exposure to discrimination and reduce suicidal thoughts," says Professor Greta Bauer from Western University, Canada. 
The authors note that other variables not covered in the study may mediate psychological distress, for example access to social support.
Writing in a linked Comment, lead author Dr Monica Malta (who was not involved in the study) from the University of Toronto says: "The cross-sectional study design prohibits causal interpretation of the identified relationships, and reverse causation is plausible--those with better mental health might be better able to navigate the difficult bureaucratic requirements to obtain gender congruent IDs. Even with those limitations, the large dataset and careful inclusion of potential confounders strengthen the study design. Thus, the authors' findings support the need to increase the availability of and streamline the processes to obtain gender congruent IDs. Gaining gender-congruent IDs should be easy, affordable, and quickly completed by adequately trained officials at TGD-friendly environments."
NOTES TO EDITORS
No funding was received for this analysis. It was conducted by researchers from the University of California San Diego, Drexel University, the University of Toronto and Western University.
If you are reporting on this study, please consider including a link to information and support for your readers. In the USA, the National Suicide Prevention Lifeline can be contacted on 1-800-273-TALK (8255) or visit https:/
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Peer-reviewed / Survey / People