Psychiatry Research 306 (2021) 114272

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Psychosis in transgender and gender non-conforming individuals: A review

of the literature and a call for more research
Sebastian M. Barr a, 1, Dominic Roberts b, 1, Katharine N. Thakkar b, c, 1, *
a
Private Practice, MA, United States
b
Department of Psychology, Michigan State University, United States
c
Department of Psychiatry and Behavioral Medicine, Michigan State University, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Epidemiological studies have described higher rates of psychotic disorder diagnoses in transgender, as compared
Schizophrenia to cisgender, individuals. With the exception of this work and a small number of published case studies, however,
Psychotic disorders there has been little consideration of gender diversity in psychosis research or clinical care. In this paper, we will
Gender diversity
review and critically evaluate the limited literature on gender diversity and clinical psychosis and articulate the
Gender identity
Gender minority stress
critical need for more work in this field, more specifically on the following areas and how they bear on clinical
Transnegativity care: 1) diagnostic biases; 2) how chronic non-affirmation and bias, gender dysphoria, and other gender minority
stressors may operate as trauma and can contribute to clinically significant psychotic symptoms; 3) the potential
impact of gender-affirming care, such as hormone therapies, on mental health and barriers for receiving such
care in transgender and nonbinary individuals; and 4) culturally-sensitive and gender-affirming approaches for
addressing psychosis. Finally, we consider ways in which researchers may engage in ethical, gender-affirming,
and accurate approaches to better address gender identity in psychosis research. We hope that such research
will aid in the creation of clinical guidelines for understanding, diagnosing, and treating psychosis in gender
diverse individuals.

1. Introduction ideologies and systems (Puckett et al., 2021), chronic non-affirmation of

Transgender (see Glossary, Table 1), or trans, individuals are at a
startlingly greater risk for mental health concerns as compared to cis­
gender individuals or general population estimates (Dhejne et al., 2016;
McNeil et al., 2017; Millet et al., 2017). Trans individuals experience
higher rates of anxiety (Bockting et al., 2013) and depression (Bockting
et al., 2013; Nemoto et al., 2011; Shipherd et al., 2010), and, alarmingly,
rates of suicide attempts have been reported to be 22 times greater than
population estimates (Adams et al., 2017a). This increased risk has been
largely attributed to several important psychosocial factors that include:
gender minority stress (Hendricks and Testa, 2012) whereby trans­
gender people experience social stressors (e.g. stigma, discrimination,
and violence) and internalized stressors (e.g., concealment, internalized
stigma) as a result of oppressive and marginalizing cisnormative
gender identity (Parr and Howe, 2019), and gender dysphoria (Lindley
and Galupo, 2020). Despite this mental health risk, the impact of
holding a marginalized gender identity on understanding, diagnosing,
and treating psychosis in those that demonstrate or indicate a need for
care2—which we refer to here as clinical psychosis—has been largely
neglected. In the current paper, we aim to critically evaluate the
epidemiological literature reporting rates of psychotic disorders among
trans individuals and highlight critical areas for future research,
including the potential for diagnostic biases, unique potential factors in
the development of clinical psychosis in transgender people, and the
impact of gender-affirming care in treating clinical psychosis. Finally, in
order to develop a more complete understanding of how holding a
minoritized gender identity bears on etiology and treatment efficacy in
psychosis, we encourage accurate and affirming reporting of gender in

Author positionality statement: Authorship is alphabetical by last name as all authors contributed equally to this manuscript. One author self-identifies as a white
man who is transgender, one author self-identifies as a white, cisgender man, and one author self-identifies as a bi-racial, cisgender woman.
* Corresponding author at: Department of Psychology, 316 Physics Road, East Lansing, MI 48823, United States.
E-mail address: kthakkar@msu.edu (K.N. Thakkar).
1
All authors contributed equally
2
We note here that many people experience psychotic symptoms without demonstrating a need for care (e.g., Johns and van Os, 2001).

https://doi.org/10.1016/j.psychres.2021.114272
Received 29 September 2021; Accepted 3 November 2021
Available online 6 November 2021
0165-1781/© 2021 Elsevier B.V. All rights reserved.
S.M. Barr et al.
Table 1
Definitions of terms used throughout the article.
Term Definition
Transgender, trans Adjectives describing people whose gender identity
and sex assigned at birth do not align based on
traditional expectations. This is a broad category
inclusive of multiple gender identities, including
men/boys and women/girls, individuals who do not
identify with a particular gender (agender people),
and people who hold gender identities outside of the
Western binary gender paradigm (e.g. two-spirit,
genderqueer, gender fluid, bigender, and nonbinary
people).
Cisgender Adjective describing people whose gender identity
aligns with society’s expectations based on their sex
assigned at birth.
Nonbinary Adjective describing people and/or gender identities
outside of the Western binary gender paradigm of two
discrete gender options: man/boy and woman/girl.
Cisnormativity The assumption that a person’s gender identity and
expression align with their assigned sex and/or gender
role expectations associated with that sex.
Non-affirmation of gender Behaviors and actions that signal to a person that they
identity are not being viewed or accepted as the gender they
know themselves to be (e.g., misgendering via use of
incorrect pronouns).
Gender dysphoria Distress related to incongruence between a person’s
gender and their assigned sex, gendered aspects of
their body, and/or others’ perceptions of their gender.
Biological sex A constellation of characteristics, including
chromosomal makeup (specifically absence or
presence of Y), sex hormones, primary reproductive
anatomy, and secondary sex characteristics (i.e., post-
pubertal characteristics developed in response to sex
hormones).
Sex assignment / sex A category designated for an infant, typically based on
assigned at birth visible genitalia.
Transnegativity Stigma against trans people and gender diversity
Gender modality The relationship between a person’s gender and their
sex assigned at birth; e.g., transgender and cisgender
are gender modalities. (This is a relatively new but
very useful term – see Ashley (2021b) for more.)
scientific work.
2. Review and synthesis of epidemiology literature
Current literature suggests that the prevalence rates of schizophrenia
spectrum disorders are elevated among individuals in the trans com­
munity (Table 2). This is evident from small clinic-based studies
reporting that persons who have received a diagnosis of gender
dysphoria or gender identity disorder (a diagnosis that has since been
dropped from diagnostic manuals due to its inappropriate pathologizing
of nonconforming gender identities; Fraser et al., 2010; Winters, 2006)
show rates of schizophrenia spectrum disorders ranging from 0.85%
(Cole et al., 1997) to 3.67% (Judge et al., 2014), which are higher than
the estimated prevalence rates in similar age groups (0.25%− 0.56%;
IMHE, 2018). Larger epidemiological studies report even more striking
elevations in the prevalence rates of schizophrenia spectrum disorders in
trans individuals, as compared to both global prevalence rates and to
similarly sampled cisgender individuals. In these studies, transgender
people are reported to be 3 (Dragon et al., 2017) to 49.7 times (Becer­
ra-Culqui et al., 2018) more likely to be diagnosed with a schizophrenia
spectrum disorder than cisgender persons. While current data strongly
suggests increased rates of a schizophrenia spectrum disorder diagnosis
among trans individuals, there is large variation in the magnitude of this
difference across studies. A review of the literature reveals several po­
tential reasons for this variability.
First, differences in the study sample—and specifically, demographic
differences between cisgender and transgender individuals—may ac­
count for some variance in reported prevalence of schizophrenia
2
Psychiatry Research 306 (2021) 114272
spectrum disorder in transgender and cisgender individuals. For
example, in two of the four large epidemiological studies reviewed
(Becerra-Culqui et al., 2018; Dragon et al., 2017; Hanna et al., 2019;
Wanta et al., 2019), transgender and cisgender groups were not matched
on either age or race3 (Dragon et al., 2017; Hanna et al., 2019). In these
studies, transgender individuals were, on average, 17 years younger and
more likely to identify as Black or African American than their cisgender
counterparts (Dragon et al., 2017; Hanna et al., 2019). Importantly, the
symptom presentation of schizophrenia spectrum disorders changes
over time, with positive symptoms becoming less severe and negative
symptoms remaining stable or increasing with age (Austin et al., 2015).
Thus, clinical comparison of the younger transgender and older cis­
gender samples in Dragon et al. (2017) and Hanna et al. (2019) may be
muddied by age differences in symptom presentation. Furthermore,
given that Black and African American people are overrepresented
among those diagnosed with schizophrenia (Schwartz and Blankenship,
2014) due to diagnostic biases (Neighbors et al., 2003) and systemic
disparities that engender poor mental health in persons with marginal­
ized identities (Alegria et al., 2016; Clark et al., 1999), the findings of
increased prevalence of schizophrenia spectrum disorders of Dragon
et al. (2017) and Hanna et al. (2019) may be at least partly confounded
by race. While differences in sample composition across studies may
contribute to some of the variation in prevalence rates of schizophrenia
spectrum disorders in transgender as compared to cisgender persons,
they do not appear to solely account for the elevated risk of schizo­
phrenia spectrum disorder in the transgender community. Indeed,
Becerra-Culqui et al. (2018) observed highly elevated rates of a
schizophrenia spectrum disorder diagnosis in trans, as compared to
cisgender, adolescents despite matching for age and race.
Another factor which may account for the variance in reported rates
of schizophrenia spectrum disorders among transgender people is
recruitment strategy. While some studies recruited participants from
small clinics that specialize in transition-related healthcare (Cole et al.,
1997; de Vries et al., 2011; Gomez-Gil et al., 2009; Judge et al., 2014),
other studies obtained their sample through retrospective reviews of
medical records and insurance claims (Becerra-Culqui et al., 2018;
Dragon et al., 2017; Hanna et al., 2019; Wanta et al., 2019). Given that
these medical and insurance record reviews are likely to include inpa­
tient records, the prevalence rates of schizophrenia spectrum disorders
in these studies would be expected to be higher than in those studies that
recruited from outpatient facilities. In support of this argument, while
Hanna et al. (2019) found that transgender individuals were at elevated
risk for schizophrenia, the prevalence of schizophrenia spectrum disor­
ders in their cisgender sample was also elevated compared to
age-standardized estimated prevalence rates (2.8% vs 0.33%; Global
Burden of Disease Collaborative Network, 2018), indicating that their
study likely overestimates the true prevalence rate of schizophrenia
spectrum disorders.
Differences in the ways in which transgender identity was oper­
ationalized across studies may also contribute to the variability in re­
ported prevalence rates of schizophrenia spectrum disorders. Across
studies, participants have been identified as transgender on the basis of a
formal diagnosis of gender dysphoria or GID as established by clinical
interview (de Vries et al., 2011; Gomez-Gil et al., 2009; Judge et al.,
2014) or the presence of related ICD codes (Becerra-Culqui et al., 2018;
Dragon et al., 2017; Hanna et al., 2019; Wanta et al., 2019) or on the
basis of a person’s self-identified gender identity (Cole et al., 1997).
Given that not all individuals identifying as transgender meet the
criteria for a diagnosis of gender dysphoria or historically GID (Ashley,
2021c) and electronic medical reviews have been shown to underesti­
mate the population prevalence of a trans identity when compared to
self-report (Zhang et al., 2020), studies using ICD codes or gender
3
Here we acknowledge race as a sociopolitical—not biological—construct
(Smedley and Smedley, 2005).
S.M. Barr et al. Psychiatry Research 306 (2021) 114272

Table 2
Characteristics of studies reporting the prevalence of schizophrenia spectrum disorders in trans persons.
Reference Sample Trans Identity Psychosis Age Range Recruited from Reported prevalence Estimated
Operationalized Operationalized rate Prevalence for Age
Group

Hanna et al. Reviewed 254 million ICD codes 302.5x, ICD and CCS 18–65+ NIS database; a Psychosis in trans
(2019) discharge records for 302.6, 302.85 codes Cisgender large publicly persons: 14.7%
in patient encounters. Psychosis: ICD mean age: available database Psychosis in
Trans persons were codes 295.00 – 57.2 of inpatient cisgender persons:
younger, more likely 298.8, 299,310, Trans mean encounters 4.3%
to identify as Black or 299.11 age: 40.3 Schizophrenia in
African American and Schizophrenia: trans persons: 14.2%
had a higher rate of CCS 659 Schizophrenia in
non-elective cisgender perons:
admissions than were 2.8%
cisgender persons in
this sample
Dragon et al. Reviewed 39 million ICD codes 302.5x, ICD codes 18–85+ CMS Chronic Schizophrenia:
(2017) Medicare fee-for- 302.6, 302.85 Schizophrenia: Cisgender Conditions Data 22.1% for trans
service claims. Trans 295.x mean age: Warehouse Medicare
persons were younger Schizophrenia 70.9 beneficiaries with
and more likely to and other Trans mean chronic conditions
identify as Black or psychotic age: 53.1 (MBCC)
African American disorders: 2.3% for cisgender
than were cisgender 293.81, 293.82, Medicare
persons in this sample. 295.x, 297.x, 298. beneficiaries with
Trans persons were x chronic conditions
also more likely to (MBCC)
qualify for Medicare 28.2% for trans
based on disability, MBCC entitled on
whereas cisgender disability only
persons were more 9.6% for cisgender
likely to be entitled MBCC entitled on
due to age. disability only
6.7% for trans MBCC
entitled on age only
0.9% for cisgender
MBCC entitled on
age only
Schizophrenia and
other psychotic
disorders: 26.7% for
trans Medicare
beneficiaries (MD)
with potentially
disabling conditions
5.6% for cisgender
MB with potentially
disabling conditions
36.3% for trans MB
with potentially
disabling conditions
entitled on disability
only
13.0% for cisgender
MB with potentially
disabling conditions
entitled on disability
only
13.3% for trans MB
with potentially
disabling conditions
entitled on age only
4.1% for cisgender
MB with potentially
disabling conditions
entitled on age only
Becerra-Culqui Medical records of 3 ICD codes 302.5x, ICD codes 10–17 KP record database Prevalence given as 0.01% for ages
et al. (2018) Kaiser Permanente 302.3, 302.6, 302.85 Psychosis: 297.1, odd ratios to referent 10–14 (Global
sites. Identified and the presence of the 297.3, 298.8, group. Burden of Disease
records of children/ following keywords in 298.9, 301.22 Psychoses in trans Collaborative
adolescents with a case notes: transgender, Schizophrenia women: 4.5% Network, 2018)1
Trans identity transsexual, transvestite, Spectrum 19.5 times higher 0.10% for ages
between Jan 1, 2006 – gender identity, gender disorders: 295.x than cisgender 15–19 (Global
Dec 31, 2014 dysphoria, gender reference males, 12.2 Burden of Disease
Identified 588 trans reassignment times higher than Collaborative
women + 745 trans cisgender reference Network, 2018)1
(continued on next page)

3
S.M. Barr et al. Psychiatry Research 306 (2021) 114272

Table 2 (continued )
Reference Sample Trans Identity Psychosis Age Range Recruited from Reported prevalence Estimated
Operationalized Operationalized rate Prevalence for Age
Group

men. females
These records were Psychoses in trans
matched with 10 male men: 4.9%
and 10 female 12.2 times higher
cisgender referees per than cisgender
case. Each person was reference males, 14.4
matched on age, race, times higher than
and recruitment site. cisgender reference
Total sample: 21,000 females
Schizophrenia in
trans women: 1.2%
49.7x higher than
cisgender reference
males, 24.9 times
higher than
cisgender reference
females
Schizophrenia in
trans men:
2.0%
21.7 times higher
than cisgender
reference males, 32.6
times higher than
cisgender reference
females
Wanta et al. Reviewed 53.5 million ICD codes 302.3, DSM-diagnoses Median Explorys Inc Schizophrenia in
(2019) electronic health 302.5x, 302.6, 302.85 for schizophrenia age: 35–39 database trans persons: 2.5%
records of persons + schizoaffective for both Schizophrenia in
seeking clinical care disorder groups cisgender persons:
0.37%
Schizoaffective in
trans persons: 2.2%
Schizoaffective in
cisgender persons:
0.16%
De Vries et al. 105 adolescents with Diagnosis of GID based Diagnosis of 14.6 years Adolescents 0% 0.01% for ages
(2011) gender dysphoria on an extensive schizophrenia referred to the 10–14 (Global
diagnostic procedure based on DISC Gender Identity Burden of Disease
Clinic of VU Collaborative
University Medical Network, 2018)1
Center, Amsterdam 0.10% for ages
15–19 (IMHE,
2018)1
Cole et al. 435 individuals with Self-reported gender Mental-health Trans Individuals who Schizophrenia in 0.54% for age
(1997) self-diagnosed gender dysphoria history taken by women presented a gender Trans women: 3/ 30–34 (Global
dysphoria researchers mean age: identity clinic 318 = 0.94% Burden of Disease
Diagnoses of 32 years Schizophrenia in Collaborative
schizophrenia Trans men Trans men: 1/117 = Network, 2018)1
made using DSM- mean age: 0.85%
III R criteria 30 years
Gomez-Gil et al. 230 trans persons who GID diagnoses based on Psychotic disorder Trans Hospital Clínic Psychotic disorder in 0.54% for males
(2009) presented with semi-structured as diagnosed by women (Barcelona, Spain) Trans women: 2.5% aged 25–34 (
complaints of gender interview, DSM-IV + MINI mean age: Psychotic disorder in Morgan et al.,
dysphoria between ICD criteria 29.7 years Trans men: 2.8% 2012)2
2000 and 2006 Trans men 0.35% for females
mean age: age 25–34 (
27.3 years Morgan et al.,
2012)2
Judge et al. 218 persons with Confirmed diagnosis of Presence of Trans Gender dysphoria Schizophrenia in 0.54% for age
(2014) gender dysphoria GD from a mental schizophrenia women clinic, Department Trans women: 8/ 30–34 (Global
health professional diagnosis mean age: of Endocrinology, 159 = 5.03% Burden of Disease
using DSM-IV or DSM-V reported in 32.5 years St. Columcille’s Schizophrenia in Collaborative
criteria medical record Trans men Hospital Trans men: 0/59 = Network, 2018)1
mean age: 0%
32.2 years Overall prevalence
rate: 3.67%
Spanos et al. Retrospective review Self-identification as Official diagnosis 21 – 30 Equinox Center, AU Schizophrenia in 0.44% for 25–29
(2021) of 589 persons seeking trans or gender diverse of schizophrenia years old trans persons: 2.4% years old (Global
services at a Gender on medical record Mean age: Schizoaffective Burden of Disease
Diverse Health Center 25 years disorder in trans Collaborative
old persons: 0.7% Network, 2018)1
Schizoaffective
disorder: 0.3% (
(continued on next page)

4
S.M. Barr et al.
Table 2 (continued )
Reference Sample Trans Identity Psychosis
Operationalized Operationalized
Meybodi et al. 83 persons with Diagnosis of GID Diagnosis of a
(2014) gender dysphoria according to the DSM-4 psychotic disorder
according to the
Persian SCID
1
General prevalence rate of schizophrenia as reported by research.
2
General prevalence rate of psychotic disorder as reported by research.
3
General prevalence rate of schizoaffective disorder as reported by research.
dysphoria diagnoses may only represent a sub-sample of the trans
community and thus over-estimate the risk of schizophrenia spectrum
disorders. Indeed, these studies typically report rates of schizophrenia
spectrum disorders that are higher than those studies which used
self-reported gender identity (Cole et al., 1997). While it is difficult to
infer the extent to which the operationalization of gender identity spe­
cifically contributes to the variance in prevalence rates across studies,
due to additional differences in sample recruitment and composition,
the reviewed studies still report rates of schizophrenia spectrum disor­
ders in trans individuals that are higher than population estimates.
It is also important to note that the existing studies on prevalence of
clinical psychosis in the trans community have not adequately consid­
ered individuals with nonbinary gender identities. Although research
has demonstrated that up to one-third of the trans community has a
gender identity that is not squarely male or female (e.g., nonbinary,
genderqueer, two-spirit; Matsuno and Budge, 2017), none of the studies
we reviewed examined psychosis prevalence in this subgroup. Many
nonbinary people experience gender dysphoria, but ignorance and bias
on the part of health care providers and systems can create barriers to
care (Taylor et al., 2019). It is thus probable that in addition to being
unexamined within the reviewed samples, nonbinary people have also
been underrepresented in these samples. The invisibility of nonbinary
people’s mental health needs has long been a problem even in the field
of trans health (Matsuno and Budge, 2017). It is imperative that future
research addresses this gap in understanding how psychosis specifically
affects nonbinary members of the trans community.
In sum, the existing literature strongly suggests that risk for schizo­
phrenia spectrum disorder diagnosis is elevated amongst transgender
individuals. However, the wide range of reported prevalence estimates
speaks to the importance of recognizing variability within the trans
community. Indeed, there are multiple factors that can moderate an
individual’s risk for developing schizophrenia, such as age (Kirkbride
et al., 2012), socioeconomic status (Werner et al., 2007), childhood
adversity (Morgan and Gayer-Anderson, 2016), and holding a margin­
alized identity (Veling et al., 2010). Yet, research into how such factors
may intersect with holding a non-cisnormative gender identity to impact
the risk of being diagnosed with a psychotic disorder is lacking. As such,
future research would benefit from recognizing and exploring the
impact of additional risk factors to more definitively understand
whether trans individuals are at increased risk for developing a
schizophrenia spectrum disorder and, if so, which factors may mediate
the relationship between holding a nonconforming gender identity and a
psychotic disorder diagnosis.
3. Critical areas of future work
Given strong suggestions from the epidemiology literature that rates
of psychotic disorder diagnoses are elevated in the trans community, we
now highlight critical areas for future research that will be important for
both understanding the reasons for increased risk as well as ways to
mitigate such risk.
5
Psychiatry Research 306 (2021) 114272
Age Range Recruited from Reported prevalence Estimated
rate Prevalence for Age
Group
Laursen et al.,
2007)3
Trans Tehran Institute of 0% 0.54% (Morgan
women: Psychiatry et al., 2012)2
25.31 years
Trans men:
25.45 years
3.1. Potential diagnostic biases
We believe that future research should prioritize examining potential
biases in diagnosing a psychotic disorder in trans individuals. Specif­
ically, we highlight the potential for trans identity and non-cisnormative
gender expression to be misconstrued as psychosis—a concern that is
based on the overdiagnosis of psychotic disorders in other marginalized
groups as well as the historical ways in which psychiatry and psychology
have promoted views that conflate transness with psychopathology.
Although it is not our position that psychotic disorders are social con­
structs, it would be willfully ignorant of the history of these fields to
deny that sociopolitical influences have played a role in shaping diag­
nostic criteria in a manner that reflects and reinforces existing hierar­
chies and moral judgements of the majority (Drescher, 2015; Fernando,
2017) and, furthermore, that normative reactions to oppression came to
be pathologized as psychosis at various points in history (Merskey and
Shafran, 1986). For example, the fight for civil rights in the United States
during the 1960′ s and 1970′ s became linked with a form of psychosis
marked by hostility and aggression in Black men (Bromberg and Simon,
1968)—an ideology that has been argued to partly account for changes
in the diagnostic criteria around that time and linked, in part, to the
appearance of striking racial disparities in a schizophrenia diagnosis
(Metzl, 2010). Even today, Black and African-American people are 2.4
times more likely to be diagnosed with schizophrenia than white people
(Olbert et al., 2018). Although certainly structural inequalities that
drive poor mental health are a large contributor to elevated rates of
psychosis—a topic that we return to later—there is empirical evidence
to support misdiagnosis, due to clinician bias and/or cultural insensi­
tivity, as one reason for the overrepresentation of a psychotic disorder
diagnosis among Black and African American individuals (Loring and
Powell, 1988).
Similarly, the fields of psychiatry and psychology have long
conflated non-cisnormative gender identities with clinical delusion and
psychopathology, and it is likely that this contributes to misdiagnosis in
current practice. The discipline of trans health in Western medicine and
psychiatry developed in the mid-20th century. These original practices
and conceptualizations of then-called transsexuality continue to shape
how our fields understand and treat trans people (shuster, 2021;
Stryker, 2017). Without appreciation of the distinctions between bio­
logical sex, sex assignment, and gender identity, knowing oneself to be a
gender that did not align with sex assignment has been historically
misunderstood by practitioners as delusional. Psychiatrists and psy­
chologists working with trans individuals in the mid-20th century
considered their patients’ gender identities and gender dysphoria to be
symptoms of schizophrenia or hysteria, and for decades it was routine
for these patients to be explicitly labeled as psychotic (shuster, 2021).
Advocacy efforts and shifts in the field have largely moved beyond this
level of explicit bias thanks to a growing body of literature that has
helped us understand gender diversity as normal and healthy. However,
physicians and therapists continue to report little-to-no training on trans
and nonbinary identities and health (Coutin et al., 2018;
S.M. Barr et al.
Obedin-Maliver et al., 2011; Parameshwaran et al., 2017) and – much
like the general population – continue to demonstrate transnegative
biases and discomfort with gender diversity (Heng et al., 2018; Roma­
nelli and Lindsey, 2020). This persistent societal trans­
negativity/cisnormativity and lack of training, paired with our fields’
not-too-distant foundations of explicit pathologization of trans people,
place diagnosticians at great risk of misinterpreting non-psychotic ex­
periences of transness or gender dysphoria as psychotic.
Indeed, some trans and nonbinary people’s experiences require that
a clinician have a thorough understanding of gender dysphoria and
gender diversity to accurately differentiate between identity develop­
ment or dysphoria and psychosis. Given that trans and nonbinary people
develop their senses of self and group membership in cisnormative so­
cieties, it can feel destabilizing to recognize a gender identity that is
different from one’s sex assigned at birth, particularly when people have
not had prior connection to trans people and the trans community
(Testa et al., 2014) or are in social and familial environments with high
levels of stigma against trans people (Katz-Wise et al., 2017). Without
language and understanding, trans people themselves may mislabel
their own experiences of identity development as psychotic. In the
following quote from musician and openly trans woman Laura Jane
Grace’s memoir, she describes how, before she knew what gender
dysphoria or transgender identity were, she worried that she may be
psychotic and used descriptions that might cause a clinician to consider
a diagnosis of a psychotic illness: “I thought I was schizophrenic, or that
my body was possessed by twin souls – one female, one male, both
wanting control” (Grace and Ozzi, 2016, P. 11).
Thus, we call, first and foremost, for more empirical work examining
clinical bias and misdiagnosis as potential contributors to the increased
rates of psychotic disorder diagnoses among trans individuals. This may
be achieved through analogue studies that ask clinicians to assess
written case studies, with some clinicians receiving information that the
client identifies as cisgender and other clinicians receiving information
the client identifies as transgender with all other information being kept
constant. This approach has been employed to evaluate biases in diag­
nostic decisions on the basis of race (e.g., Loring and Powell, 1988) and
sexual orientation (e.g., Biaggo et al., 2000). In addition, we call on
practitioners to improve diagnostic practices when working with trans
individuals generally, and especially with trans community members
with complex or severe clinical presentations. Client conceptualizations
must include a thorough understanding of individuals’ psychosocial
factors and the “intricate interplay” between gender experiences and
mental health (American Psychological Association, 2015), which can
be gathered through careful culturally competent assessment (Hanss­
mann et al., 2008). However, this level of competence in assessment and
diagnosis cannot be achieved without increasing the integration of
trans-related content into training curricula (Dubin et al., 2018). As
recently as 2018, only 34.5% of sampled psychiatry residents endorsed
that they would be ready to provide competent care to the trans com­
munity by the completion of residency (Coutin et al., 2018), with only
19.5% reporting that their education in this area was adequate. Psy­
chiatrists and clinicians trained earlier may be even less likely to endorse
or display competence in this area. Dubin et al. (2018) review the
literature on transgender healthcare training and offer multiple sug­
gestions for building or improving curricula, including emphasizing the
importance of direct patient-learner interaction with the trans commu­
nity, pedagogical intervention that improves attitudes as well as
knowledge, and more robust integration throughout training. At least one
study has demonstrated that the benefits seen from a single, standalone
workshop on trans health disparities and trans healthcare needs
diminished completely over a short follow-up period (Kidd et al., 2016),
and other research has documented that provider transnegative bias is
more predictive of competency than hours of trans-related training
received (Strousma et al., 2019).
6
Psychiatry Research 306 (2021) 114272
3.2. Unique potential factors in the development of psychosis in trans
individuals
A second priority for research is into unique factors above and
beyond diagnostic bias that might explain higher prevalence rates of
psychotic disorders in the trans community. Converging evidence sup­
ports a diathesis-stress model of psychotic symptoms, whereby an
intrinsic biological risk towards psychosis interacts with social and
environmental stressors to influence the development of symptoms
(Andreasen, 1999; Bleuler, 1963; Rosenthal, 1963). Such social and
environmental contributors to schizophrenia symptoms include (but are
not limited to) interpersonal stressors like discrimination (Pearce et al.,
2019) bullying (Catone et al., 2018), and childhood trauma (Kelleher
et al., 2013)—risk factors whose commonality has been described as the
"negative experience of being excluded from the majority group" (Selten
et al., 2013) and are, in part, a byproduct of systemic inequalities and
oppression. Indeed, recent work has explicitly linked structural racism
in the United States with psychosis risk (Anglin et al., 2021), and
discrimination, bullying, and childhood trauma have been found to
mediate moderate to large portions of psychosis risk in LGB populations
(Gevonden et al., 2014; (Post et al., 2021))
Trans people report much higher rates of childhood trauma,
bullying, and discrimination experiences than the general population (e.
g., Barr et al., 2021; Day et al., 2018; James et al., 2016),4 thus creating
particular vulnerabilities that likely increase risk for psychotic disorders,
though no known research has established this link specifically within
the trans community. Additional experiences unique to the trans com­
munity may create vulnerability to the development of psychosis.
Beyond discrimination, the gender minority stressors of gender
dysphoria and non-affirmation of gender are also associated with sig­
nificant distress and increased severity of psychiatric symptoms,
including PTSD (Barr et al., 2021; Lindley and Galupo, 2020). Trans
people report that both gender incongruence (between identity and
body and/or between identity and social designations/perceptions of
gender) and chronic invalidation are incredibly painful and can be dis­
orienting (Austin et al., 2021; Cooper et al., 2020; Galupo et al., 2020).
The accumulation of these experiences can have a destabilizing effect
and contribute to profound stress on one’s psyche. Thus, the experience
of knowing oneself to be a gender which is different from how one is
labeled and perceived can not only be misinterpreted as psychotic by a
non-culturally-competent diagnostician, but this experience can also
give rise to destabilization which can make the development of psy­
chotic illness more likely. The field would benefit from research that
explored oppression- and non-affirmation predictors of both psychotic
symptoms and diagnoses of psychotic illness in the trans community, as
well as the potential relationship of gender dysphoria to the develop­
ment of psychosis. Given the documented impact of multiple margin­
alization on psychiatric and health risk (e.g., Lefevor et al., 2019;
Reinka et al., 2020; Velez et al., 2014), research in this area must take an
intersectional lens.
Another relevant factor for interpreting increased prevalence rates of
psychotic disorders within the trans community is substance use.
Accumulating evidence supports a link between substance use and
psychosis such that substance use, particularly cannabis, can both
induce acute psychosis (Fiorentini et al., 2011) and increase the risk of
4
For example, a recent study of more than 500 transgender adults found that
93% had experienced anti-trans discrimination in their lifetimes, 79% had
experienced anti-trans victimization in their lifetimes, and more than 1 in 3
reported childhood sexual and/or physical abuse (Barr, et al., 2021). Surveys
assessing trans people’s school experiences have consistently documented
bullying and harassment rates of well over 50% (Grant et al., 2011; James et al.,
2016; Witcomb et al., 2019). Prevalence rates are consistently higher among
trans people with intersecting minoritized and marginalized identities (e.g.
BIPOC trans people and trans women; Grant et al., 2011).
S.M. Barr et al.
more chronic psychotic symptoms. Indeed, meta-analyses suggest that
cannabis use increases the risk of developing a chronic psychotic dis­
order in a dose-response fashion (Marconi et al., 2016), a finding which
is supported by longitudinal data demonstrating that cannabis use can
give rise to, or worsen existing, psychotic symptoms in young adoles­
cence (Fergusson et al., 2003). Research has demonstrated prevalence
rates of excessive substance use in the trans community that are higher
than what is typically found in the general population. This increased
risk is partially mediated by gender minority stress (e.g., external and
internalized stigma), gender dysphoria, and gender non-affirmation
(Connolly and Gilchrist, 2020; Gonzalez et al., 2017). Research
exploring the possible link between substance use in the trans commu­
nity and prevalence rates of clinical psychosis would provide needed
insight into another potential mechanism for increased psychosis risk, as
well as opportunities for community-based prevention efforts.
3.3. Impact of gender affirmation on mental health
Research has consistently demonstrated that within the trans com­
munity, social and medical gender affirmation is associated with
improved psychological functioning, less severe psychiatric symptoms,
and reduced utilization of mental healthcare (Baker et al., 2021; Bran­
strom and Pachankis, 2020; Hughto et al., 2020; Wernick et al., 2019;
White Hughto and Reisner, 2016). Gender affirmation through both
social and medical/physical channels (e.g., coming out as a different
gender, changing presentation via clothing or hair, undergoing hormone
therapy to masculinize or feminize appearance, surgical interventions to
change primary or secondary sex characteristics, etc.) often reduces
experiences of non-affirmation (e.g., being incorrectly gendered) and
gender dysphoria related to body dissatisfaction. Given that
non-affirmation and gender dysphoria can be extremely psychologically
disruptive (Austin et al., 2021; Cooper et al., 2020; Galupo et al., 2020),
it should not be a surprise that reduction of non-affirmation and
dysphoria are associated with overall improved mental health. We hy­
pothesize that this phenomenon would extend to trans and nonbinary
individuals with clinical psychosis, as well, such that for some, gender
affirmation would reduce severity of psychosis and/or improve overall
mental health and functioning. Further research on the impact of gender
affirmation on psychotic symptoms will aid providers in better treat­
ment planning and expectation setting with clients at the intersection of
psychosis and gender dysphoria.
Importantly, however, trans and nonbinary individuals with psy­
chosis and other severe mental illness currently face added barriers to
accessing gender affirmation (Peta, 2020), often preventing them from
experiencing critical relief from gender dysphoria. Because of the
aforementioned historical diagnostic biases in our field and the dual
stigma of severe mental illness and non-cisnormative identity, clinicians
and staff may be dismissive of individuals’ stated genders, blocking
access to even social affirmation (e.g., refusing to use the pronouns a
patient requests). Clinicians may also be reluctant to endorse access to
gender-affirming medical care if a person displays signs or reports his­
tory of psychosis. This denial of services, however, is not consistent with
best practice if clients demonstrate a consistent pattern of transgender
identity and gender dysphoria and have the capacity to engage in
informed consent (Deutsch, 2016; Henin et al., 2022). In fact, delaying
or denying gender affirmation may be harmful and further destabilizing
(Clark et al., 2018; Donnelly-Boylen, 2016), and experts have high­
lighted that gender dysphoria can be easily differentiated from experi­
ences of psychosis through thoughtful clinical interview and review of
patients’ histories (Byne et al., 2018). Further, there are a small number
of published case studies documenting gender-affirming medical in­
terventions and consequent successful reduction of gender dysphoria in
trans patients with psychosis (Gerken et al., 2016; Janssen et al., 2019;
Meijer et al., 2017). Given the positive and protective role gender
affirmation often has on trans people’s mental health (American Psy­
chological Association; Assoc, 2015), it is particularly critical that
7
Psychiatry Research 306 (2021) 114272
people with severe mental illness have access to potentially helpful in­
terventions. We call on researchers to assess the mental health impact of
existing barriers to gender-affirming care, specifically for trans people
with psychosis. We further call on clinicians and institutions to work to
reduce barriers that do not serve the best interests of the trans
community.
3.4. Culturally-sensitive and gender-affirming approaches for addressing
psychosis
A further priority for research is in effective care approaches for trans
people with psychosis. As outlined in an earlier section, there are likely
unique potential factors that may confer risk to psychosis in transgender,
as compared to cisgender, individuals. Indeed, schizophrenia is perhaps
most accurately characterized as a equifinal syndrome, whereby a di­
versity of pathways may lead to mechanistically disparate but clinically
similar syndromes (Green and Glausier, 2016). Accordingly, treatment
adaptations are required to address these unique environmental risk
processes in trans individuals (Coyne et al., 2020).
Thus, we call on researchers and clinicians to better understand the
trans community’s specific needs in receiving treatment and care related
to psychosis and to develop and test approaches that meet these needs.
Here we consider the focus of treatment to be not necessarily the un­
usual beliefs and experiences that characterize psychosis, but rather
their associated distress, as hallucinations and delusions are not always
subjectively experienced as a negative outcome (Feyaerts et al., 2021;
Sommer et al., 2010), together with subjective wellbeing and role
functioning. Unfortunately, there has been limited mental health inter­
vention research in trans clients specifically (Budge et al., 2017), and
this is doubly true for trans people with clinical psychosis. There is only
one known published longitudinal RCT focused on mental health in­
terventions for trans people, and it expressly excluded individuals with
psychotic symptoms (Budge et al., 2021).
Along with developing effective interventions, we also highlight the
need to improve access to and utilization of mental health interventions
within the trans community (Snow et al., 2019). Trans peoples’ barriers
to mental healthcare include lack of clinician competence, avoidance of
care due to previous negative experiences or fear of mistreatment, and
issues related to financial and structural accessibility (e.g., cost of care,
transportation, ability to take off work or keep track of scheduled ap­
pointments, etc.; James et al., 2016; Shipherd et al., 2010). Although
this has not been studied, it is reasonable to be concerned that the dual
stigma of trans identity and severe mental illness would further heighten
such barriers. Additionally, individuals with clinical psychosis are more
likely to need and/or receive crisis or inpatient mental health care, but
trans patients may experience anti-trans bias in emergency departments
(Samuels et al., 2018), and trans people’s experiences in inpatient and
residential settings are often discriminatory and/or non-affirming
(Walton and Baker, 2019).
Finally, while we have heretofore been considering clinically sig­
nificant psychosis as an outcome in individuals with a non-cisnormative
gender, we would also like to highlight the work of mental health ac­
tivists who have solidified madness—a term reclaimed by these
activists—as a sociopolitical identity in its own right (Gorman and
LeFrançois, 2017; Schrader et al., 2013). Thus, within a multicultural
treatment framework, clinicians may also consider the client’s back­
ground as it pertains to their alignment with a mad identity and how that
bears on core values (Schrader et al., 2013).
3.5. Ethical, gender-affirming, and accurate approaches to scientific
research
As we have reviewed, epidemiological data document diagnostic
disparities on the basis of gender modality. However, there is strikingly
little data investigating the mechanisms of these disparities and their
implications. Throughout this paper we have highlighted specific gaps in
S.M. Barr et al.
the literature and called for research to address them. We also recognize
that scientific inquiry on issues related to gender diversity and/or with
trans samples can be done in harmful ways, and the fields of psychology
and psychiatry have oftened engage in ethically compromised research
with trans communities. Drawing upon the work of many trans scholars
(e.g., Adams et al., 2017b; Ansara and Hegarty, 2014; Ashley, 2021a;
Kronk et al., 2021; Vincent, 2018), we offer some recommendations to
better address gender identity in psychosis research. First and foremost,
we recommend accurate and affirming collection and reporting of
gender and assigned sex. At a minimum, we advise that researchers
familiarize themselves with the differences between gender identity and
sex assigned at birth and consider adopting a multi-step method that
does not conflate these two questions and provides options that are
comprehensive and affirming. In considering response options for such
questions, we encourage researchers to consider how they reflect the
lived experiences of members of the trans community. Puckett et al.
(2020) provide a helpful list of recommendations for asking questions
about sex at birth and gender in scientific research that is based on input
from the trans community. Finally, we would like to highlight the
importance of including impacted community members—transgender
individuals, individuals experiencing/diagnosed with psychosis,5 and
their intersections—on research teams and community advisory boards.
Such community-based participatory research may engender research
questions and methods that are better aligned with and reflective of the
lived experience of trans individuals experiencing psychosis, provide a
more accurate interpretation of findings, and help convey findings in a
way that is accessible to the communities served (Adams et al., 2017b;
Kalathil and Jones, 2016; Tebbe and Moradi, 2016).
References
Adams, N., Hitomi, M., Moody, C., 2017a. Varied reports of adult transgender suicidality:
synthesizing and describing the peer-reviewed and gray literature. Transgend.
Health 2 (1), 60–75.
Adams, N., Pearce, R., Veale, J., Radix, A., Castro, D., Sarkar, A., Thom, K.C., 2017b.
Guidance and ethical considerations for undertaking transgender health research
and institutional review boards adjudicating this research. Transgend. Health 2 (1),
165–175.
Alegria, M., Alvarez, K., Ishikawa, R.Z., DiMarzio, K., McPeck, S., 2016. Removing
obstacles to eliminating racial and ethnic disparities in behavioral health care.
Health Aff. 35 (6), 991–999.
American Psychological Association, 2015. Guidelines for Psychological Practice With
Transgender and Gender Nonconforming People. American Psychologist 70 (9), 832-
864.
Andreasen, N.C., 1999. Understanding the causes of schizophrenia. N. Engl. J. Med. 340
(8), 645–647.
Anglin, D.M., Ereshefsky, S., Klaunig, M.J., Bridgwater, M.A., Niendam, T.A., Ellman, L.
M., DeVylder, J., Thayer, G., Bolden, K., Musket, C.W., Grattan, R.E., Lincoln, S.H.,
Schiffman, J., Lipner, E., Bachman, P., Corcoran, C.M., Mota, N.B., van der Ven, E.,
2021. From womb to neighborhood: a racial analysis of social determinants of
psychosis in the United States. Am. J. Psychiatry 178 (7), 599–610.
Ansara, Y.G., Hegarty, P., 2014. Methodologies of misgendering: recommendations for
reducing cisgenderism in psychological research. Fem. Psychol. 24 (2), 259–270.
Ashley, F., 2021c. The misuse of gender dysphoria: toward greater conceptual clarity in
transgender health. Perspect. Psychol. Sci. 16 (6), 1159–1164, 1745691619872987.
Ashley, F., 2021a. Accounting for research fatigue in research ethics. Bioethics 35 (3),
270–276.
Ashley, F., 2021b. ‘Trans’ is my gender modality: a modest terminological proposal. In:
Erickson-Schroth, L. (Ed.), Trans Bodies, Trans Selves, second ed. Oxford University
Press.
Assoc, A.P., 2015. Guidelines for psychological practice with transgender and gender
nonconforming people. Am. Psychol. 70 (9), 832–864.
Austin, A., Holzworth, J., Papciak, R., 2021. Beyond diagnosis: “Gender dysphoria feels
like a living hell, a nightmare one cannot ever wake up from”. Psychol. Sex. Orientat.
Gend. Divers.
Austin, S.F., Mors, O., Budtz-Jorgensen, E., Secher, R.G., Hjorthoj, C.R., Bertelsen, M.,
Jeppesen, P., Petersen, L., Thorup, A., Nordentoft, M., 2015. Long-term trajectories
of positive and negative symptoms in first episode psychosis: a 10year follow-up
study in the OPUS cohort. Schizophr. Res. 168 (1–2), 84–91.
5 Altamura, C.A., 2011. Substance-induced psychoses: a critical review of the
We take the opportunity to note here that there are no authors that identify
as having lived experience with psychosis and acknowledge the limitations
thereof.
8
Psychiatry Research 306 (2021) 114272
Baker, K.E., Wilson, L.M., Sharma, R., Dukhanin, V., McArthur, K., Robinson, K.A., 2021.
Hormone therapy, mental health, and quality of life among transgender people: a
systematic review. J. Endocr. Soc. 5 (4) bvab011.
Barr, S.M., Snyder, K.E., Adelson, J.L., Budge, S.L., 2021. Posttraumatic stress in the trans
community: the roles of antitransgender bias, non-affirmation, and internalized
transphobia. Psychol. Sex. Orientat. Gend. Divers.
Becerra-Culqui, T.A., Liu, Y., Nash, R., Cromwell, L., Flanders, W.D., Getahun, D.,
Giammattei, S.V., Hunkeler, E.M., Lash, T.L., Millman, A., Quinn, V.P., Robinson, B.,
Roblin, D., Sandberg, D.E., Silverberg, M.J., Tangpricha, V., Goodman, M., 2018.
Mental health of transgender and gender nonconforming youth compared with their
peers. Pediatrics 141 (5), e20173845.
Biaggo, M., Roades, L.A., Staffelbach, D., Cardinali, J., Duffy, R., 2000. Clinical
evaluations: impact of sexual orientation, gender, and gender role. J. Appl. Soc.
Psychol. 30 (8), 1657–1669.
Bleuler, M., 1963. Conception of schizophrenia within the last fifty years and today
[abridged]. Proc. R. Soc. Med. 56 (10), 945–952.
Bockting, W.O., Miner, M.H., Swinburne Romine, R.E., Hamilton, A., Coleman, E., 2013.
Stigma, mental health, and resilience in an online sample of the US transgender
population. Am. J. Public Health 103 (5), 943–951.
Branstrom, R., Pachankis, J.E., 2020. Reduction in mental health treatment utilization
among transgender individuals after gender-affirming surgeries: a total population
study. Am. J. Psychiatry 177 (8), 727–734.
Bromberg, W., Simon, F., 1968. The "protest" psychosis. A special type of reactive
psychosis. Arch. Gen. Psychiatry 19 (2), 155–160.
Budge, S.L., Israel, T., Merrill, C.R.S., 2017. Improving the lives of sexual and gender
minorities: the promise of psychotherapy research. J. Couns. Psychol. 64, 376–384.
Budge, S.L., Sinnard, M.T., Hoyt, W.T., 2021. Longitudinal effects of psychotherapy with
transgender and nonbinary clients: a randomized controlled pilot trial.
Psychotherapy 58 (1), 1–11.
Byne, W., Karasic, D.H., Coleman, E., Eyler, A.E., Kidd, J.D., Meyer-Bahlburg, H.F.L.,
Pleak, R.R., Pula, J., 2018. Gender dysphoria in adults: an overview and primer for
psychiatrists. Transgend. Health 3 (1), 57–70.
Catone, G., Marwaha, S., Lennox, B., Broome, M.R., 2018. Bullying victimisation and
psychosis: the interdependence and independence of risk trajectories. BJPsych Adv.
23 (6), 397–406.
Clark, B.A., Veale, J.F., Greyson, D., Saewyc, E., 2018. Primary care access and foregone
care: a survey of transgender adolescents and young adults. Fam. Pract. 35 (3),
302–306.
Clark, R., Anderson, N.B., Clark, V.R., Williams, D.R., 1999. Racism as a stressor for
African Americans. A biopsychosocial model. Am. Psychol. 54 (10), 805–816.
Cole, C.M., O’Boyle, M., Emory, L.E., Meyer 3rd, W.J., 1997. Comorbidity of gender
dysphoria and other major psychiatric diagnoses. Arch Sex Behav 26 (1), 13–26.
Connolly, D., Gilchrist, G., 2020. Prevalence and correlates of substance use among
transgender adults: a systematic review. Addict. Behav. 111, 106544.
Cooper, K., Russell, A., Mandy, W., Butler, C., 2020. The phenomenology of gender
dysphoria in adults: a systematic review and meta-synthesis. Clin. Psychol. Rev. 80,
101875.
Coutin, A., Wright, S., Li, C., Fung, R., 2018. Missed opportunities: are residents prepared
to care for transgender patients? A study of family medicine, psychiatry,
endocrinology, and urology residents. Can. Med. Educ. J. 9 (3), e41–e55.
Coyne, C.A., Poquiz, J.L., Janssen, A., Chen, D., 2020. Evidence-based psychological
practice for transgender and non-binary youth: defining the need, framework for
treatment adaptation, and future directions. Evidence-based practice. Child Adolesc.
Ment. Health 5 (3), 340–353.
Day, J.K., Perez-Brumer, A., Russell, S.T., 2018. Safe schools? Transgender youth’s
school experiences and perceptions of school climate. J. Youth Adolesc. 47 (8),
1731–1742.
de Vries, A.L., Doreleijers, T.A., Steensma, T.D., Cohen-Kettenis, P.T., 2011. Psychiatric
comorbidity in gender dysphoric adolescents. J. Child Psychol. Psychiatry Allied
Discipl. 52 (11), 1195–1202.
Deutsch, M.B., 2016. Guidelines for the Primary and Gender-Affirming Care of
Transgender and Gender Nonbinary People. University of California, San Francisco.
Dhejne, C., Van Vlerken, R., Heylens, G., Arcelus, J., 2016. Mental health and gender
dysphoria: a review of the literature. Int. Rev. Psychiatry 28 (1), 44–57.
Donnelly-Boylen, K., 2016. Gender dysphoria, serious mental illness, and genital self-
mutilation: a case report. J. Gay Lesbian Ment. Health 20 (4), 376–381.
Dragon, C.N., Guerino, P., Ewald, E., Laffan, A.M., 2017. Transgender medicare
beneficiaries and chronic conditions: exploring fee-for-service claims data. LGBT
Health 4 (6), 404–411.
Drescher, J., 2015. Out of DSM: depathologizing Homosexuality. Behav. Sci. 5 (4),
565–575.
Dubin, S.N., Nolan, I.T., Streed Jr., C.G., Greene, R.E., Radix, A.E., Morrison, S.D., 2018.
Transgender health care: improving medical students’ and residents’ training and
awareness. Adv. Med. Educ. Pract. 9, 377–391.
Fergusson, D.M., Horwood, L.J., Swain-Campbell, N.R., 2003. Cannabis dependence and
psychotic symptoms in young people. Psychol. Med. 33 (1), 15–21.
Fernando, S., 2017. Institutional Racism in Psychiatry and Clinical Psychology: Race
matters in Mental Health. Palgrave Macmillian, Basingstoke.
Feyaerts, J., Henriksen, M.G., Vanheule, S., Myin-Germeys, I., Sass, L.A., 2021. Delusions
beyond beliefs: a critical overview of diagnostic, aetiological, and therapeutic
schizophrenia research from a clinical-phenomenological perspective. Lancet
Psychiatry 8 (3), 237–249.
Fiorentini, A., Volonteri, L.S., Dragogna, F., Rovera, C., Maffini, M., Mauri, M.C.,
literature. Curr. Drug Abuse Rev. 4 (4), 228–240.
S.M. Barr et al.
Fraser, L., Karasic, D.H., Meyer, W.J., Wylie, K., 2010. Recommendations for revision of
the DSM diagnosis of gender identity disorder in adults. Int. J. Transgend. 12, 80–85.
Galupo, M.P., Pulice-Farrow, L., Lindley, L., 2020. Every time I get gendered male, I feel
a pain in my chest”: understanding the social context for gender dysphoria. Stigma
Health 5, 199–208.
Gerken, A.T., McGahee, S., Keuroghlian, A.S., Freudenreich, O., 2016. Consideration of
clozapine and gender-affirming medical care for an HIV-positive person with
schizophrenia and fluctuating gender identity. Harv. Rev. Psychiatry 24 (6),
406–415.
Gevonden, M.J., Selten, J.P., Myin-Germeys, I., de Graaf, R., ten Have, M., van
Dorsselaer, S., van Os, J., Veling, W., 2014. Sexual minority status and psychotic
symptoms: findings from the Netherlands Mental Health Survey and Incidence
Studies (NEMESIS). Psychol. Med. 44 (2), 421–433.
Gomez-Gil, E., Trilla, A., Salamero, M., Godas, T., Valdes, M., 2009. Sociodemographic,
clinical, and psychiatric characteristics of transsexuals from Spain. Arch. Sex. Behav.
38 (3), 378–392.
Gonzalez, C.A., Gallego, J.D., Bockting, W.O., 2017. Demographic characteristics,
components of sexuality and gender, and minority stress and their associations to
excessive alcohol, cannabis, and illicit (noncannabis) drug use among a large sample
of transgender people in the United States. J. Prim. Prev. 38 (4), 419–445.
Gorman, R., LeFrançois, 2017. Mad Studies. In: Cohen, B.M.Z. (Ed.), Routledge
International Handbook of Critical Mental Health, first ed. Routledge, London.
Grace, L.J., Ozzi, D., 2016. Tranny: Confessions of Punk Rock’s Most Infamous Anarchist
Sellout. Hachette Books.
Grant, J.M., Mottet, L.A., Tanis, J., Harrison, J., Herman, J.L., Keisling, M., 2011.
Injustice At Every Turn: A Report of the National Transgender Discrimination
Survey. National Center for Transgender Equality and National Gay and Lesbian
Task Force, Washington, D.C.
Green, I.W., Glausier, J.R., 2016. Different paths to core pathology: the equifinal model
of the schizophrenia syndrome. Schizophr. Bull. 42 (3), 542–549.
Hanna, B., Desai, R., Parekh, T., Guirguis, E., Kumar, G., Sachdeva, R., 2019. Psychiatric
disorders in the U.S. transgender population. Ann. Epidemiol. 39, 1–7 e1.
Hanssmann, C., Morrison, D., Russinan, E., 2008. Talking, gawking, or getting it done:
provider trainings to incrase cultural and clinical competence for transgender and
gender-noncomforming patients and clients. Sex. Res. Soc. Policy 5 (1), 5–23.
Hendricks, M.L., Testa, R.J., 2012. A conceptual framework for clinical work with
transgender and gender nonconforming clients: an adaptation of the minority stress
model. Profess. Psychol. 43 (5), 460–467.
Heng, A., Heal, C., Banks, J., Preston, R., 2018. Transgender peoples’ experiences and
perspectives about general healthcare: a systematic review. Int. J. Transgend. 19,
359–378.
Henin, A., Darsney, C., Vaz De Souza, F., 2022. Behavioral Health Considerations for
Transgender and Gender Diverse people, Transgender and Gender Diverse Health
Care: the Fenway Guide. McGraw Hill.
Hughto, J.M.W., Gunn, H.A., Rood, B.A., Pantalone, D.W., 2020. Social and medical
gender affirmation experiences are inversely associated with mental health problems
in a U.S. non-probability sample of transgender adults. Arch. Sex. Behav. 49 (7),
2635–2647.
IMHE, 2018. Global Burden of Disease Study 2017 (GBD 2017) Results. Institute for
Health Metrics and Evaluation (IHME), Seattle, United States.
James, S.E., Herman, J.L., Rankin, S., Keisling, M., Mottet, L., Anafi, M., 2016. The
Report of the 2015 U.S. Transgender Survey. National Center for Transgender
Equality, Washington, D.C.
Janssen, A., Busa, S., Wernick, J., 2019. The complexities of treatment planning for
transgender youth with co-occurring severe mental illness: a literature review and
case study. Arch. Sex. Behav. 48 (7), 2003–2009.
Johns, L.C., van Os, J., 2001. The continuity of psychotic experiences in the general
population. Clin. Psychol. Rev. 21 (8), 1125–1141.
Judge, C., O’Donovan, C., Callaghan, G., Gaoatswe, G., O’Shea, D., 2014. Gender
dysphoria - prevalence and co-morbidities in an Irish adult population. Front.
Endocrinol. 5, 87.
Kalathil, J., Jones, N., 2016. Unsettling disciplines: madness, identity, research,
knowledge. Philos. Psychiatry Psychol. 23, 183–188.
Katz-Wise, S.L., Budge, S.L., Fugate, E., Flanagan, K., Touloumtzis, C., Rood, B., Perez-
Brumer, A., Leibowitz, S., 2017. Transactional pathways of transgender identity
development in transgender and gender nonconforming youth and caregivers from
the trans youth family study. Int. J. Transgend. 18 (3), 243–263.
Kelleher, I., Keeley, H., Corcoran, P., Ramsay, H., Wasserman, C., Carli, V.,
Sarchiapone, M., Hoven, C., Wasserman, D., Cannon, M., 2013. Childhood trauma
and psychosis in a prospective cohort study: cause, effect, and directionality. Am. J.
Psychiatry 170 (7), 734–741.
Kidd, J.D., Bockting, W., Cabaniss, D.L., Blumenshine, P., 2016. Special-"T" training:
extended follow-up results from a residency-wide professionalism workshop on
transgender health. Acad. Psychiatry 40 (5), 802–806.
Kirkbride, J.B., Errazuriz, A., Croudace, T.J., Morgan, C., Jackson, D., Boydell, J.,
Murray, R.M., Jones, P.B., 2012. Incidence of schizophrenia and other psychoses in
England, 1950-2009: a systematic review and meta-analyses. PLoS ONE 7 (3),
e31660.
Kronk, C.A., Everhart, A.R., Ashley, F., Thompson, H.M., Schall, T.E., Goetz, T.G.,
Hiatt, L., Derrick, Z., Queen, R., Ram, A., Guthman, E.M., Danforth, O.M., Lett, E.,
Potter, E., Sun, S.E.D., Marshall, Z., Karnoski, R., 2021. Transgender data collection
in the electronic health record: current concepts and issues. J. Am. Med. Inform.
Assoc. ocab136.
Laursen, T.M., Munk-Olsen, T., Nordentoft, M., Bo Mortensen, P., 2007. A comparison of
selected risk factors for unipolar depressive disorder, bipolar affective disorder,
9
Psychiatry Research 306 (2021) 114272
schizoaffective disorder, and schizophrenia from a Danish population-based cohort.
J. Clin. Psychiatry 68 (11), 1673–1681.
Lefevor, G.T., Boyd-Rogers, C.C., Sprague, B.M., Janis, R.A., 2019. Health disparities
between genderqueer, transgender, and cisgender individuals: an extension of
minority stress theory. J. Couns. Psychol. 66 (4), 385–395.
Lindley, L., Galupo, M.P., 2020. Gender dysphoria and minority stress: support for
inclusion of gender dysphoria as a proximal stressor. Psychol. Sex. Orientat. Gend.
Divers. 7 (3), 265–275.
Loring, M., Powell, B., 1988. Gender, race, and DSM-III: a study of the objectivity of
psychiatric diagnostic behavior. J. Health. Soc. Behav. 29 (1), 1–22.
Marconi, A., Di Forti, M., Lewis, C.M., Murray, R.M., Vassos, E., 2016. Meta-analysis of
the association between the level of cannabis use and risk of psychosis. Schizophr.
Bull. 42 (5), 1262–1269.
Matsuno, E., Budge, S.L., 2017. Non-binary/Genderqueer Identities: a Critical Review of
the Literature. Curr. Sex. Health Rep. 9, 116–120.
McNeil, J., Ellis, S.J., Eccles, F.J.R., 2017. Suicide in trans populations: a systematic
review of prevalence and correlates. Psychol. Sex. Orientat. Gend. Divers. 4 (3),
341–353.
Meijer, J.H., Eeckhout, G.M., van Vlerken, R.H.T., de Vries, A.L., 2017. Gender dysphoria
and co-existing psychosis: review and four case examples of successful gender
affirmative treatment. LGBT Health 4 (2), 106–114.
Merskey, H., Shafran, B., 1986. Political hazards in the diagnosis of ’sluggish
schizophrenia. Br. J. Psychiatry 148, 247–256.
Metzl, J.M., 2010. The Protest Psychosis: How Schizophrenia Became a Black Disease.
Beacon Press, Boston, MA.
Millet, N., Longworth, J., Arcelus, J., 2017. Prevalence of anxiety symptoms and
disorders in the transgender population: a systematic review of the literature. Int. J.
Transgend. 18 (1), 27–38.
Morgan, C., Gayer-Anderson, C., 2016. Childhood adversities and psychosis: evidence,
challenges, implications. World psychiatry: official. J. World Psychiatr. Assoc. 15
(2), 93–102.
Morgan, V.A., Waterreus, A., Jablensky, A., Mackinnon, A., McGrath, J.J., Carr, V.,
Bush, R., Castle, D., Cohen, M., Harvey, C., Galletly, C., Stain, H.J., Neil, A.L.,
McGorry, P., Hocking, B., Shah, S., Saw, S., 2012. People living with psychotic illness
in 2010: the second Australian national survey of psychosis. Aust. N. Zeal. J.
Psychiatry 46 (8), 735–752.
Meybodi, A.M., Hajebi, A., Jolfaei, A.G., 2014. Psychiatric Axis I Comorbidities among
Patients with Gender Dysphoria. Psychiatry Journal 971814.
Neighbors, H.W., Trierweiler, S.J., Ford, B.C., Muroff, J.R., 2003. Racial differences in
DSM diagnosis using a semi-structured instrument: the importance of clinical
judgment in the diagnosis of African Americans. J. Health Soc. Behav. 44 (3),
237–256.
Nemoto, T., Bodeker, B., Iwamoto, M., 2011. Social support, exposure to violence and
transphobia, and correlates of depression among male-to-female transgender women
with a history of sex work. Am. J. Public Health 101 (10), 1980–1988.
Global burden of Disease Collaborative Network, 2018. Global Burden of Disease Study
2017 (GBD 2017) Results. Institute for Health Metrics and Evaluation (IHME),
Seattle, United States.
Obedin-Maliver, J., Goldsmith, E.S., Stewart, L., White, W., Tran, E., Brenman, S.,
Wells, M., Fetterman, D.M., Garcia, G., Lunn, M.R., 2011. Lesbian, gay, bisexual, and
transgender-related content in undergraduate medical education. JAMA 306 (9),
971–977.
Olbert, C.M., Nagendra, A., Buck, B., 2018. Meta-analysis of Black vs. White racial
disparity in schizophrenia diagnosis in the United States: do structured assessments
attenuate racial disparities? J. Abnorm. Psychol. 127 (1), 104–115.
Parameshwaran, V., Cockbain, B.C., Hillyard, M., Price, J.R., 2017. Is the lack of specific
lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) health care
education in medical school a cause for concern? Evidence from a survey of
knowledge and practice among UK medical students. J. Homosex. 64 (3), 367–381.
Parr, N.J., Howe, B.G., 2019. Heterogeneity of transgender identity nonaffirmation
microaggressions and their association with depression symptoms and suicidality
among transgender persons. Psychol. Sex. Orientat. Gend. Divers. 6, 461–474.
Pearce, J., Rafiq, S., Simpson, J., Varese, F., 2019. Perceived discrimination and
psychosis: a systematic review of the literature. Soc. Psychiatry Psychiatr. Epidemiol.
54 (9), 1023–1044.
Peta, J.L., 2020. Schizophrenia spectrum and other psychotic disorders among sexual
and gender minority populations. In: Rothblum, E.D. (Ed.), The Oxford Handbook of
Sexual and Gender Minority Mental Health, 125-.
Post, D., Veling, W., GROUP Investigators, 2021. Sexual minority status, social adversity
and risk for psychotic disorders-results from the GROUP study. Psychol. Med. 51 (5),
770–776.
Puckett, J.A., Aboussouan, A.B., Ralston, A.L., Mustanski, B., Newcomb, M.E., 2021.
Systems of cissexism and the daily production of stress for transgender and gender
diverse people. Int. J. Transgend. Health.
Puckett, J.A., Brown, N.C., Dunn, T., Mustanski, B., Newcomb, M.E., 2020. Perspectives
from transgender and gender diverse people on how to ask about gender. LGBT
Health 7 (6), 305–311.
Reinka, M.A., Pan-Weisz, B., Lawner, E.K., Quinn, D.M., 2020. Cumulative consequences
of stigma: possessing multiple concealable stigmatized identities is associated with
worse quality of life. J. Appl. Soc. Psychol. 50, 253–261.
Romanelli, M., Lindsey, M.A., 2020. Patterns of healthcare discrimination among
transgender help-seekers. Am. J. Prev. Med. 58 (4), e123–e131.
Rosenthal, D., 1963. The Genain Quadruplets: a Case Study and Theoretical Analysis of
Heredity and Environment in Schizophrenia. Basic Books, New York, NY.
Samuels, E.A., Tape, C., Garber, N., Bowman, S., Choo, E.K., 2018. Sometimes you feel
like the freak show": a qualitative assessment of emergency care experiences among
S.M. Barr et al.
transgender and gender-nonconforming patients. Ann. Emerg. Med. 71 (2), 170–182
e171.
Schrader, S., Jones, N., Shattell, M., 2013. Mad pride: reflections on sociopolitical
identity and mental diversity in the context of culturally competent psychiatric care.
Issues Ment. Health Nurs. 34 (1), 62–64.
Schwartz, R.C., Blankenship, D.M., 2014. Racial disparities in psychotic disorder
diagnosis: a review of empirical literature. World J. Psychiatry 4 (4), 133–140.
Selten, J.P., van der Ven, E., Rutten, B.P., Cantor-Graae, E., 2013. The social defeat
hypothesis of schizophrenia: an update. Schizophr. Bull. 39 (6), 1180–1186.
Shipherd, J.C., Green, K.E., Abramovitz, S., 2010. Transgender clients: identifying and
minimizing barriers to mental health treatment. J. Gay Lesbian Ment. Health 14 (2),
94–108.
shuster, s.m., 2021. Trans Medicine: the Emergence and Practice of Treating Gender.
NYU Press, New York, NY.
Smedley, A., Smedley, B.D., 2005. Race as biology is fiction, racism as a social problem is
real: anthropological and historical perspectives on the social construction of race.
Am. Psychol. 60 (1), 16–26.
Snow, A., Cerel, J., Loeffler, D.N., Flaherty, C., 2019. Barriers to mental health care for
transgender and gender-nonconforming adults: a systematic literature review.
Health Soc. Work 44 (3), 149–155.
Sommer, I.E., Daalman, K., Rietkerk, T., Diederen, K.M., Bakker, S., Wijkstra, J., Boks, M.
P., 2010. Healthy individuals with auditory verbal hallucinations; who are they?
Psychiatric assessments of a selected sample of 103 subjects. Schizophr. Bull. 36 (3),
633–641.
Spanos, C., Grace, J.A., Leemaqz, S.Yl, Brownhill, A., Cundill, P., Locke, P., Wong, P.,
Zajack, J.D., Cheung, A.S., 2021. The Informed Consent Model of Care for Accessing
Gender-Affirming Hormone Therapy Is Associated with High Patient Satisfaction.
The Journal of Sexual Medicine 18, 201-208.
Strousma, D., Shires, D.A., Richardson, C.R., Jaffee, K.D., Woodford, M.R., 2019.
Transphobia rather than education predicts provider knowledge of transgender
health care. Med. Educ. 53, 398–407.
Stryker, S., 2017. Transgender History: the Roots of Today’s Revolution, second ed. Seal
Press, New York, NY.
Taylor, J., Zalewska, A., Gates, J.J., Millon, G., 2019. An exploration of the lived
experiences of non-binary individuals who have presented at a gender identity clinic
in the United Kingdom. Int. J. Transgend. 20, 195–204.
10
Psychiatry Research 306 (2021) 114272
Tebbe, E.A., Moradi, B., 2016. Suicide risk in trans populations: an application of
minority stress theory. J. Couns. Psychol. 63 (5), 520–533.
Testa, R.J., Jimenez, C.L., Rankin, S., 2014. Risk and resilience during transgender
identity development: the effects of awareness and engagement with other
transgender people on affect. J. Gay Lesbian Ment. Health 18, 31–46.
Velez, B.L., Moradi, B., D’eBlaere, C., 2014. Multiple oppressions and the mental health
of sexual minority latina/o individuals. Couns. Psychol. 43, 7–38.
Veling, W., Hoek, H.W., Wiersma, D., Mackenbach, J.P., 2010. Ethnic identity and the
risk of schizophrenia in ethnic minorities: a case-control study. Schizophr. Bull. 36
(6), 1149–1156.
Vincent, B.W., 2018. Studying trans: recommendations for ethical recruitment and
collaboration with transgender participants in academic research. Psychol. Sex. 9
(2), 102–116.
Walton, H., Baker, S.L., 2019. Treating transgender individuals in inpatient and
residential mental health settings. Cogn. Behav. Pract. 26 (4), 592–602.
Wanta, J.W., Niforatos, J.D., Durbak, E., Viguera, A., Altinay, M., 2019. Mental health
diagnoses among transgender patients in the clinical setting: an all-payer electronic
health record study. Transgend. Health 4 (1), 313–315.
Werner, S., Malaspina, D., Rabinowitz, J., 2007. Socioeconomic status at birth is
associated with risk of schizophrenia: population-based multilevel study. Schizophr.
Bull. 33 (6), 1373–1378.
Wernick, J.A., Busa, S., Matouk, K., Nicholson, J., Janssen, A., 2019. A systematic review
of the psychological benefits of gender-affirming surgery. Urol. Clin. North Am. 46
(4), 475–486.
White Hughto, J.M., Reisner, S.L., 2016. A systematic review of the effects of hormone
therapy on psychological functioning and quality of life in transgender individuals.
Transgend. Health 1 (1), 21–31.
Winters, K., 2006. Gender dissonance. J. Psychol. Human Sex. 17, 71–89.
Witcomb, G.L., Claes, L., Bouman, W.P., Nixon, E., Motmans, J., Arcelus, J., 2019.
Experiences and psychological wellbeing outcomes associated with bullying in
treatment-seeking transgender and gender-diverse youth. LGBT Health 6 (5),
216–226.
Zhang, Q., Goodman, M., Adams, N., Corneil, T., Hashemi, L., Kreukels, B., Motmans, J.,
Snyder, R., Coleman, E., 2020. Epidemiological considerations in transgender health:
a systematic review with focus on higher quality data. Int. J. Transgend. Health 21
(2), 125–137.