Irish transgender voices on mental health and mental health care

Purpose – People who identify as transgender face stigma, isolation and harassment while often struggling to come to terms with their gender identity. They also disproportionately experience mental health difficulties. The purpose of this paper is to present the voices of transgender people in the Republic of Ireland (RoI) in regard to the issues they are facing, improvements they would like to see made to schools, workplaces, services and society in general and whether mental health supports fulfil theirneeds. Design/methodology/approach – Ten open questions were embedded within a quantitative online survey (LGBTIreland study) on factors impacting social inclusion, mental health and care. These open questions were re-analysed with exclusive focus on the transgender participants ( n = 279) using content/ thematicanalysis. Findings – The participants in this study reported significant signs of mental distress. The following themes emerged: impact of stigma, deficiencies in mental health services, need for education on transgender identity,importanceofpeersupport,achievingself-acceptanceandsocietalinclusionquestioned. Research limitations/implications – Efforts to recruit young participants have led to a possible over-representationinthis study. Practical implications – The findings suggest the need for improvement in mental health support services,includingfurthereducationinhowtomeetthe needsoftransgender individuals. Social implications – Transgender people in Ireland experience social exclusion. The need for more inclusivity was emphasised most in secondary schools. Education on transgender identities in all contexts ofsocietyis recommendedbythe participants. Originality/value – This study reports on the largest group of transgender participants to date in RoI. Theirvoices will affect perceptions onsocialinclusion and mental health care.


Introduction
People who identify as transgender are routinely exposed to discrimination, bullying, harassment, stigma and isolation, often summarised as minority stress (Meyer, 2003). This has led to elevated rates of mental health problems among this group, also in the Republic of Ireland (RoI) (Mayock et al., 2009;McNeil et al., 2013;Judge et al., 2014;Higgins et al., 2016;de Vries et al., 2022). While research internationally has demonstrated that gender-affirming treatment reduces mental health concerns (Mueller, 2020), appropriate mental health support during this journey is important. Whether this is available in the RoI is questioned. A review of research in RoI highlights that mental health professionals often lack specific training, are hard to access and costly and are not well prepared to work in partnership with transgender people (Collins and Sheehan, 2004;Higgins et al., 2011;Mullen and Moane, 2013;McCann, 2015;TENI, 2017;Hodgins et al., 2020). Recent developments, notably the introduction of same-sex (Information about the authors can be found at the end of this article.) marriage, overwhelmingly supported by a referendum, and legislation around gender diversity, are indicative of progress in Irish society. However, it is not clear to what extent this affects daily life, mental health and health care of this group. This paper addresses in concise fashion how transgender people themselves viewed factors impacting their mental health, the supports received and social inclusion and is based on further qualitative analysis of data from a larger study focused on all lesbian, gay, bisexual, transgender, queer and intersex (LGBTQIþ) communities in Ireland (the LGBTIreland study) (Higgins et al., 2016;de Vries et al., 2022). The overall project was instigated in response to concerns raised within these communities and in past research (Mayock et al., 2009;TENI, 2017). The specific analysis of responses from transgender participants was motivated by the dearth in efforts in the RoI to give a voice to this group.

Procedure
Ten qualitative questions were embedded in an online survey (SurveyMonkey Inc.) to explore mental health determinants and mental health-care experiences of the LGBTQIþ communities (see Table 2).

Participants
Recruitment took place with the assistance of local and national social, health, youth and LGBTQIþ organisations who promoted the study through posters, radio, websites, social media and events. Any person who identified as LGBTQIþ, was 14 years of age or over and living in the ROI was eligible to participate.

Analysis
Data were first extracted and reviewed, which showed that considerable overlap occurred in the responses to the ten questions. Consequently, a combined thematic analysis in NVivo (QSR International Pty Ltd, 2020) was performed. Braun and Clarke's (2006) six steps were used: familiarizing, creating codes, comparing codes and findings, reviewing and naming themes and reporting the findings. The analysis was completed by two researchers to minimize interpretative bias and possible preconceptions were "bracketed" (Tufford and Newman, 2012). A mix of cisgender and LGBTQIþ members included in the research team helped ensure balanced reporting, with emphasis on the voices of the participants. Moreover, theoretical bias was prevented from dominating because of the multi-disciplinary composition of the team (social sciences, mental health and nursing).

Ethical considerations
Ethical approval was received from the Trinity College Dublin Faculty of Health Research Ethics Committee. Participating in the survey included informed consent. The requirement for parental consent for those aged under 18 years was waived to include adolescents who might not have disclosed their identity to parents/guardians. The survey was anonymous, and data handling was in compliance with General Data Protection Regulation, the Helsinki Agreement (World Medical Association, 2013) and the Data Protection (Amendment) Act 2003. Quotes included in this publication have been anonymized where necessary.

Demographics
Demographics of the 279 participants who identified as transgender show that about half of the participants were 25 years or younger. A majority reported no religion. The educational level varied. Most lived in an urban or a suburban area. A majority lived together with parents or others. Over a third of participants were still in education, whereas nearly a third of the sample were unemployed. A minority reported having a relationship with a partner, and most did not have children. Those who were "out" to everyone formed a minority, but most were living in their desired gender full-time or part-time. Although all participants identified as transgender, many also used additional terms to describe their gender identity (see Table 1).

Response to the questions
Most responses (see Table 2) were received in answer to question 3 (232 (83%), whereas 186 (66%) answered question 8 and 160 (57%) responded to question 2. The response rate for other questions was lower, but sizeable enough to justify analysis. Responses varied in length, often appearing well considered, suggesting a genuine effort to inform the research.

Thematic analysis outcomes
Following a process of amalgamating related aspects, six overarching themes were identified ( Table 3). The overview presented here is representative of the content and mood of the responses. Quotes are followed by participant number, gender identifier provided by participant in addition to identifying as transgender, age and question number.

Impact of transgender stigma (theme 1).
First and foremost, participants emphasised that they were living in a society that was still considered ill disposed towards transgender people. Stigma and fear for one's physical and psychological safety was expressed in many responses:  Need for education on transgender identity 4 Importance of peer support 5 Achieving self-acceptance 6 Societal inclusion questioned Feeling unsafe was also expressed in relation to personal contacts, friends and family, although the emphasis here was mostly on feeling mentally unsafe or unsupported: I just wish I could disclose what I think my sexual orientation actually is, but I fear that my authentic gender identity will be rendered invalid by others in my life. (#1192, male, 26, q10) Deficiencies in mental health services (theme 2).
Participants found mental health services and professionals not well prepared to work with transgender people and sometimes biased against them. This was considered the most significant obstacle to seeking help. In addition, costs, waiting lists, lack of availability in rural areas and parents who did not support help seeking were mentioned: Need for education on transgender identity (theme 3).
Participants were proposing education and training not only for therapists but also for the general population, schools and for whoever encounters transgender identity individuals: Importance of peer support (theme 4).
Support from peers was frequently mentioned as essential in "coming out" and maintaining mental health. Support organisations were mentioned on more than one occasion: Meeting other trans and lesbian women. Also finding the organization BelongTo [LGBT young people's organisation, www.belongto.org/]. (#241, female with trans history, 19, q3) Some nationwide organisations were mentioned, but most third level colleges have their own societies that provide meaningful support: Joining the LGBTQCISAP society in my university helped. Having an information leaflet to give to people instead of having to explain the entire concept of transgender myself, helped. Society without gender binaries would.
These organisations were mentioned to provide assistance in a number of ways, including providing help for their members in "coming out": Coming Out workshops were useful. (#1614, male, 23, q3) While such workshops were mentioned, most of the support highlighted was of an informal kind. In essence, the organisations opened avenues for developing friendships, often to compensate for a lack thereof within the participants' families and schools: The support by fellow LGBTQI was great. Meeting people, getting involved and knowing that I have my chosen family to go to if my birth family do not accept me. (#1345, male to female, 17, q3) the friendships I made with similar minded people have made a big difference and improved my confidence, before coming out I was very shy and reserved and suffered greatly from panic attacks. Also knowing that my life is just as important as say heterosexual people has made me stronger mentally and not being treated as a third class citizen in a two class society has helped too.
The importance of working towards self-acceptance was mentioned by several participants. Many described their inner turmoil. This was particularly prominent in participants in their teens for whom the process of self-acceptance was in its early stages: I feel too scared to join a support group, because I worry that I'm not trans enough. I wish I'd been born a woman, but the consequences of transitioning seem so much worse than the discomfort I feel living in the wrong body. I wish I wanted to transition. How I am now is just confusing. (#2195, male with desire to transition, 18, q10) Other participants made it clear that they had to come to terms not only with their gender identity but also their sexual orientation: Everyone has a gender identity and everyone has a sexual orientation. You need to accept both. How our mental health is shaped is related to the interconnectedness of these identities. (#2205, male transgender, 51, q10) The need for exploration and effort in achieving acceptance was also highlighted. The following is an example in which again both gender identity and sexuality are mentioned: I wish I had come to terms with my sexuality at a much younger age as I only really accepted I was bi AFTER I was in a relationship with my now-husband. I think would feel more comfortable with my identity if I had actually explored that side of myself while I was single. (But I don't think my mental health problems have anything much to do with my orientation. I am a bit of a mess for many other reasons.) The final quote under this theme illustrates the vantage point of someone who managed to overcome obstacles and achieved a degree of self-acceptance, which she describes as a sense of "inner peace": Coming to terms with being trans has [.] granted me a great deal of inner peace which has done nothing but improve my overall mental health. While the road to getting treatment was extremely frustrating, now that I am on treatment I'm optimistic of my personal growth going forward, both physically and mentally. (#96, transwoman between stages, 24, q9) Societal inclusion questioned (theme 6).
Overall, cautious signals were given that progress in RoI was noted, in terms of social and cultural climate and also in legal terms. Nonetheless, the need for more legal changes was highlighted by many participants: Laws that give trans people rights and that protect them and the right to express their gender identity. (#1209, male, 48, q9) Some participants were unsure whether a mentality change can be expected to take place as quickly as hoped for. They expected that more time would be needed: Not sure, but with more time it will become more and more acceptable within society and with that I hope I will not even have to think about my safety. (#525, female transgender, 32, q9) On the positive side, the gradual appearance of gender-neutral bathrooms was mentioned as a sign of a change in mentality. While some complained that there was not enough of it yet, others applauded progress: My workplace is very good, for instance we have gender-neutral bathrooms, which I think is primarily due to the strong and unequivocal leadership shown by senior management on the issue, who really have their hearts in it -fair, decent and inclusive treatment for all staff. (#1019, male-to-female, 41, q7) Furthermore, the presence of transgender people in the media, already mentioned as educational under theme 3, was considered helpful as a way of normalising transgender identity and a sign of progress: Positive LGBTI representation in the media are more common these days, such as Laverne Cox's transgender character in the series Orange Is The New Black. (#2196, female, 22, q3) But while acceptance of gay and lesbian sexual orientation has improved noticeably in recent years, a few participants were of the view that this does not necessarily extend to the transgender identity:

Discussion
The findings of the study confirm the issues reported by transgender people internationally (Aylagas-Crespillo et al., 2018;Pinna et al., 2022) and in other Irish studies (Collins and Sheehan, 2004;Higgins et al., 2011;Mullen and Moane, 2013;McCann, 2015;TENI, 2017;Hodgins et al., 2020). Irish society is becoming more inclusive and more accepting of diversity, but the transgender people in our study identified limitations to this. This put pressure on their mental health, especially in secondary school. In addition, mental health care was criticised in terms of access difficulties, high cost and limited quality. Moreover, our findings confirm what has been shown elsewhere, that uninformed practitioners, and a lack of cultural humility can lead to insensitive care (Shipherd et al., 2010;Mizock and Lundquist, 2016). Our findings also confirm what an extensive American study found a decade ago, that the burden of educating practitioners often falls on transgender people themselves (Grant et al., 2011).

Implications
The traditional discourse that views gender only in binary terms and the application of ambiguous diagnostic criteria such as in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition may be part of the problem (Cohen-Kettenis and Pfä fflin, 2010; Coleman, 2017). It is evident that participants hoped for more advanced standards of mental health support for transgender people, such as outlined by the World Professional Association of Transgender Health (WPATH), to be put into practice in Ireland. WPATHs most recent update (version 8) (Coleman et al., 2022) advocates a more flexible approach to care and support, taking into account the diversity of identities and a move away from pathologising gender diversity. In particular, the requirement of a psychiatric diagnosis of "gender dysphoria" (unease resulting from a mismatch between biological gender and felt gender identity) to receive gender affirmation treatment is contentious. Considering the rise in people who identify as transgender in Ireland (Chevallier et al., 2019) and the increased diversity in how they experience this, it is imperative to develop more informed support and customised treatment options, to avoid adding to the distress of this group.
A further implication of our findings is, as the participants suggest, that more needs to be done in the RoI to provide education on gender identities. This should initially take place in schools but also be aimed at relevant professionals and the general public. Best practice principles need to be implemented and educational initiatives need to be co-produced and co-delivered by the transgender community (Higgins et al., 2019;Coleman et al., 2022) to be effective.

Strengths and limitations
The main strength of the study is the size of the sample of transgender participants, which is the largest to date in Ireland. However, as always with voluntary participation, it cannot be ascertained whether such a sample would be representative of the relevant population, which is estimated (conservatively) at 3,000 in RoI (Chevallier et al., 2019). Efforts to recruit young participants have led to a possible over-representation in this study. Finally, our data did not allow us to make comparisons based on the extent of engagement with gender affirmation treatment. This is being altered in current LGBTQIþ research in RoI.