Recent research has consistently found that bisexual people experience higher rates of poor mental health than gay, lesbian or heterosexual people.1–7 In addition, current literature indicates that transgender and gender diverse individuals experience greater psychological distress and suicidality than cisgender people (defined as those whose affirmed gender meets normative expectations given their sex assigned at birth).5,8,9 Many transgender and gender diverse people identify as bisexual, so there is a link between gender diversity and bisexuality.5 However, the ways in which bisexuality and gender diversity might both affect an individual’s mental health are not well understood.
The term ‘bisexual’ has been used since the turn of the 20th century to describe a person who is attracted to both men and women.10 However, in recent times, definitions have moved away from an attraction-only approach to incorporate aspects such as desire, behaviour, political and social affiliations and self-applied identity.3 Yoshino’s inclusive three-axes approach to bisexual orientation includes people who have bisexual identity, attraction and/or experience.11
The term ‘transgender’ typically refers to people whose affirmed gender differs from the normative expectations given their sex assigned at birth.12 Someone who is transgender may be a man or a woman or they may identify as gender diverse. ‘Gender diverse’ is another umbrella term used to describe people who do not identify as a man or a woman but as both genders or neither. People under the gender diverse umbrella may identify as agender, gender fluid, non-binary, gender non-conforming or other similar terms.
Experiences of bisexuality may be different for transgender and gender diverse people than for cisgender people. Research shows an association between poorer mental health and experiences of discrimination, harassment, denial or invisibility of identity, and alienation from families or communities. Both bisexual people and transgender and gender diverse people are vulnerable to these experiences, but they may manifest in different ways. For instance, transgender and gender diverse people may experience more overt harassment or discrimination than cisgender people because of their gender presentation. However, they may not experience the same sense of invisibility or ‘erasure’ of identity that cisgender bisexual people report. One study comparing the effects of bisexual-specific minority stress on cisgender and transgender bisexual people found that transgender bisexual people reported poorer physical health when compared with cisgender women, which was linked to marginalisation and discrimination against transgender people.13
This article provides an important addition to the small body of literature examining mental health among transgender and gender diverse bisexual people. The article supplements the authors’ previously published article reporting on the mental health findings of the cisgender cohort of the ‘Who I Am’ study.14
Methods
The ‘Who I Am’ study was a cross-sectional survey of Australian adults (aged ≥18 years) who identified as bisexual and/or were attracted to more than one gender and/or had had sexual experiences with more than one gender. Data were collected from September 2016 to March 2017. A total of 2651 people completed the survey, of whom 474 (17.8%) were transgender or gender diverse.
As a result of the anticipated challenges of recruiting participants from a characteristically invisible and dispersed population, convenience sampling was used. A detailed recruitment strategy included online advertising via Facebook, online and print media, promotion through professional networks and print advertising distributed to universities and sexual health centres across the country. The advertisements varied, with some including the words ‘bisexual’ and ‘pansexual’ and others simply calling for people ‘attracted to more than one gender’.
The survey included standard demographic questions (Table 1) as well as questions relating to bisexual life experiences known to affect mental health: perceived biphobia (prejudice/poor treatment based on bisexual orientation), sense of bisexual invisibility and deliberate erasure of bisexuality by others being ‘out’, sense of community and belonging, and intimate relationships. These questions were developed by the researchers following an extensive literature review, community consultation and piloting. Relevant helpline numbers were provided to participants.
| Table 1. Survey questions devised by researchers |
| Question |
Response options |
| Mental health past and present |
|
A health professional has said I have …
In the past I think I have had …
I currently think I have …
|
Anxiety disorder
Depression
Bipolar disorder
Schizophrenia
Borderline personality disorder
Eating disorder
Dissociative identity disorder
Post-traumatic stress disorder
Obsessive compulsive disorder
Attention deficit hyperactivity disorder
Other |
In the past two years have you …
Have you ever … |
Thought about self-harming
Harmed yourself
Thought about committing suicide
Attempted suicide |
| Biphobia* |
Have you ever been treated badly because of your sexuality?
Have you ever been treated badly by your family because of your sexuality?
Have you ever been treated badly by your friends because of your sexuality?
Do you ever feel that your sexuality is bad or wrong? |
Never
Rarely
Sometimes
Often
Always |
| Invisibility and erasure* |
Do people ever assume you are heterosexual/straight?
Do people ever assume you are gay or lesbian?
Do you ever wish that your sexuality was more visible to those around you?
Do you ever feel that those around you refuse to accept your sexuality and/or believe that your sexuality does not exist? |
Never
Rarely
Sometimes
Often
Always |
| Being ‘out’* |
Who in your life is aware of your sexuality?
Immediate family
Extended family
Closest friends
Broader friendship group |
All
Some
None
Not applicable |
| Community and belonging† |
How often do you participate in LGBTI community events (eg social gatherings, cultural, festivals/celebrations etc)?
How often do you participate in bisexual or pansexual community events (eg social gatherings, cultural, festivals/celebrations etc)?
How often do you have contact with LGBTI friends or acquaintances?
How often do you have contact with bisexual or pansexual friends or acquaintances? |
Never
Rarely
Sometimes
Often
Always |
| Intimate relationships‡ |
| Is your partner/partners aware that your sexual identity, sexual attraction and/or sexual behaviour incorporates people of your own gender and at least one other gender? |
Yes
No
Don’t know |
| Is your partner/partners understanding and supportive of your sexuality that incorporates people of your own gender and at least one other gender? |
Very understanding and supportive
Somewhat understanding and supportive
Neither supportive nor unsupportive
Somewhat unsupportive and lacking understanding
Very unsupportive and lacking understanding |
| How many partners do you have? |
One partner only
One partner + casual sex with other people
One primary partner + one or more other regular partners
One primary partner + one or more other regular partners + casual sex with other people
Two or more partners whom I see as equal in my life
Two or more partners whom I see as equal in my life + casual sex with other people
Other |
| What is the gender of your primary partner/s? |
I have more than one primary partner and
they are of different genders
Man/men
Woman/women
Trans man/men
Trans woman/women
Non-binary or gender diverse
Other |
*These questions were preceded by the statement: ‘The following questions ask about your life experiences as a person whose sexual attraction, sexual behaviour and/or sexual identity incorporates people of your own gender and at least one other gender. In places we have simply referred to this as your “sexuality”.’
†LGBTI was defined prior to these questions as relating to lesbian, gay, bisexual, transgender and intersex.
‡These questions were preceded by the statement: ‘The following questions are about your current relationship/s. If you are not currently in a relationship please answer these thinking about your most recent relationship. If you have never been in a relationship please leave this section blank and skip to the next page.’ |
Mental health was measured using the Kessler Psychological Distress Scale (K10),15 a standardised and frequently used measure of current psychological distress.15,16 K10 scores range from 10 to 50, with higher scores indicating greater psychological distress. Scores were grouped into four categories used by the Australian Bureau of Statistics: low (10–15), moderate (16–21), high (22–29) and very high (30–50).16
Data were analysed using IBM SPSS Version 25 software. Participants were included in the transgender and gender diverse subset if they identified as a ‘trans man’, ‘trans woman’, ‘non-binary or gender diverse’ or ‘other’ and those who identified their gender to be ‘man’ or ‘woman’ but indicated a different assigned sex at birth. Partial Spearman’s rank-order correlation tests were used to identify correlations between bisexual life experience variables and K10 categories while controlling for demographic variables. Bisexual life experience variables were included in an ordinal logistic regression model if they were found to have a statistically significant (P <0.05) relationship with K10 categories at the bivariate level. Chi-square tests and post-hoc analyses were used to compare cisgender and transgender and gender diverse people on K10 outcomes and bisexual life experiences.
Ethics approval for the ‘Who I Am’ study was granted by La Trobe University’s Human Ethics Committee and the community-based ACON (formerly the AIDS Council of New South Wales) Research Ethics Review Committee.
Results
Of transgender and gender diverse participants (n = 474) in the ‘Who I Am’ study, the majority identified their gender as ‘non-binary or gender diverse’ (60%; Table 2). Ages ranged from 18 years to 69 years, with a mean age of 27.91 years. Participants from all states and territories in Australia took part in the study, with just over 80% residing in inner or outer suburban areas (Table 2).
| Table 2. Sample characteristics |
| Characteristic |
Frequency |
Percentage (%) |
| Gender (n = 474) |
| Trans man |
63 |
13.3 |
| Trans woman |
60 |
12.7 |
| Non-binary or gender diverse |
285 |
60.1 |
| Other |
66 |
13.9 |
| Age group in years (n = 474) |
| 18–24 |
236 |
49.8 |
| 25–44 |
193 |
40.7 |
| ≥45 |
45 |
9.5 |
| Aboriginal and/or Torres Strait Islander origin (n = 471) |
| Yes |
14 |
3.0 |
| No |
457 |
96.4 |
| Ethnicity (n = 470) |
| Anglo–Australian |
378 |
79.7 |
| Other |
92 |
19.4 |
| State or territory currently residing (n = 474) |
| Vic |
163 |
34.4 |
| NSW |
94 |
19.8 |
| Qld |
54 |
11.4 |
| WA |
49 |
10.3 |
| Tas |
44 |
9.3 |
| ACT |
38 |
8.0 |
| SA |
30 |
6.3 |
| NT |
2 |
0.4 |
| Local area description (n = 474) |
| Capital city/inner suburban |
244 |
51.5 |
| Outer suburban |
137 |
28.9 |
| Regional centre |
62 |
13.1 |
| Rural or remote |
31 |
6.5 |
| Highest level of education achieved (n = 464) |
| Year 10 or below |
26 |
5.5 |
| Year 11 |
16 |
3.4 |
| Year 12 |
142 |
30.0 |
| Apprenticeship/trade certificate/tertiary diploma |
104 |
21.9 |
| Undergraduate university degree |
119 |
25.1 |
| Postgraduate university degree |
57 |
12.0 |
| Total pre-tax income per year (n = 474) |
| $0 |
25 |
5.3 |
| $1–$29,999 |
258 |
54.4 |
| $30,000–$49,999 |
63 |
13.3 |
| $50,000–$79,999 |
55 |
11.6 |
| $80,000–$99,999 |
14 |
3.0 |
| $100,000–$124,999 |
12 |
2.5 |
| $125,000–$149,999 |
1 |
0.2 |
| $150,000–$199,999 |
1 |
0.2 |
| ≥$200,000 |
4 |
0.8 |
| Prefer not to answer |
41 |
8.6 |
| Relationship status (n = 424) |
| In a relationship |
241 |
56.8 |
| Single |
183 |
43.2 |
The mean K10 score was 27.09 (standard deviation = 9.30). The majority of the sample reported high or very high psychological distress (72%; Table 3). The most frequently reported mental health diagnoses were depression, anxiety, post-traumatic stress disorder, eating disorders and borderline personality disorder (Table 3). Participants were asked if they felt that they had symptoms of a mental health disorder, such as depression or anxiety. For nearly all disorders, there was a substantial number of participants who reported being diagnosed with a condition who did not indicate they felt they had symptoms (Table 3). Rates of suicidality and self-harm were very high, with nearly half the sample (49%) having ever attempted suicide (Table 3).
| Table 3. Mental health past and present |
| Characteristic |
Frequency |
Percentage (%) |
| K10 category (n = 399) |
| Low (10–15) |
52 |
13.0 |
| Moderate (16–21) |
61 |
15.3 |
| High (22–29) |
126 |
31.6 |
| Very high (30–50) |
160 |
40.1 |
| In the past I think I have had … (n = 413) |
| Anxiety disorder |
134 |
28.3 |
| Depression |
147 |
31.0 |
| Bipolar disorder |
20 |
4.2 |
| Schizophrenia |
4 |
0.8 |
| Borderline personality disorder |
26 |
5.5 |
| Eating disorder |
88 |
18.6 |
| Dissociative identity disorder |
22 |
4.6 |
| Post-traumatic stress disorder |
63 |
13.3 |
| Obsessive compulsive disorder |
6 |
1.3 |
| Attention deficit hyperactivity disorder |
2 |
0.4 |
| Other |
6 |
1.3 |
| I currently think I have … (n = 413) |
| Anxiety disorder |
138 |
29.1 |
| Depression |
114 |
24.1 |
| Bipolar disorder |
23 |
4.9 |
| Schizophrenia |
8 |
1.7 |
| Borderline personality disorder |
30 |
6.3 |
| Eating disorder |
26 |
5.5 |
| Dissociative identity disorder |
24 |
5.1 |
| Post-traumatic stress disorder |
56 |
11.8 |
| Obsessive compulsive disorder |
7 |
1.5 |
| Attention deficit hyperactivity disorder |
4 |
0.8 |
| Other |
11 |
2.3 |
| A health professional has said I have … (n = 413) |
| Anxiety disorder |
264 |
63.9 |
| Depression |
290 |
70.2 |
| Bipolar disorder |
44 |
10.7 |
| Schizophrenia |
13 |
3.1 |
| Borderline personality disorder |
48 |
11.6 |
| Eating disorder |
52 |
12.6 |
| Dissociative identity disorder |
16 |
3.9 |
| Post-traumatic stress disorder |
73 |
17.7 |
| Obsessive compulsive disorder |
10 |
2.4 |
| Attention deficit hyperactivity disorder |
11 |
2.7 |
| Other |
26 |
6.3 |
| A health professional has said I have one of the above mental health disorders (n = 413) |
| Yes |
325 |
78.7 |
| No |
88 |
21.3 |
| In the past two years have you … |
| Thought about self-harming (n = 408) |
260 |
63.7 |
| Harmed yourself (n = 406) |
166 |
35.0 |
| Thought about committing suicide (n = 406) |
259 |
54.6 |
| Attempted suicide (n = 406) |
60 |
12.7 |
| Have you ever … |
| Thought about self-harming (n = 408) |
365 |
89.5 |
| Harmed yourself (n = 406) |
305 |
75.1 |
| Thought about committing suicide (n = 408) |
372 |
91.6 |
| Attempted suicide (n = 406) |
198 |
48.8 |
| K10, Kessler Psychological Distress Scale |
Experiences of biphobia and erasure, and less participation in lesbian, gay, bisexual, transgender and intersex (LGBTI) community events, were found to be significantly correlated with poorer mental health at the bivariate level (Table 4).
The ordinal logistic regression model statistically significantly predicted the dependent variable (K10 categories) over and above the intercept-only model (P <0.01). Two variables were significant predictors of poorer mental health: feeling that sexuality was bad or wrong, and lower levels of participation in LGBTI community events (Table 4).
| Table 4. Relationships between bisexual life experiences and K10 categories |
| |
Spearman’s rho significant findings |
Ordinal logistic regression findings |
| Bisexual life experiences significantly correlated with K10 categories |
Correlation coefficient |
Significance
(2-tailed) |
Odds ratio
(95% confidence interval) |
P value |
| Have you ever been treated badly because of your sexuality? |
0.17 |
0.001 |
1.20 (0.88, 1.64) |
0.26 |
| Have you ever been treated badly by your family because of your sexuality? |
0.19 |
<0.001 |
1.20 (0.98, 1.47) |
0.08 |
| Have you ever been treated badly by your friends because of your sexuality? |
0.14 |
0.01 |
1.03 (0.78, 1.36) |
0.85 |
| Do you ever feel that your sexuality is bad or wrong? |
0.27 |
<0.001 |
1.53 (1.23, 1.90) |
<0.001 |
| Do you ever feel that those around you refuse to accept your sexuality and/or believe that your sexuality does not exist? |
0.18 |
<0.001 |
1.17 (0.94, 1.45) |
0.17 |
| How often do you participate in LGBTI community events? |
–0.16 |
0.002 |
0.72 (0.59, 0.88) |
0.001 |
| K10, Kessler Psychological Distress Scale; LGBTI, lesbian, gay, bisexual, transgender and intersex |
Transgender and gender diverse respondents were significantly more likely to report very high levels of psychological distress than cisgender respondents (χ2[1] = 25.33, P <0.01). In addition, transgender and gender diverse respondents were significantly more likely to report experiencing five of the six ‘bisexual life experiences’ found to be associated with poorer mental health in the previous analyses (listed in Table 4). Transgender and gender diverse respondents were also significantly more likely to have experienced biphobia: ‘Have you ever been treated badly because of your sexuality?’ (χ2[1] = 83.80, P <0.01); ‘Have you ever been treated badly by family?’ (χ2[1] = 111.53, P <0.01) and ‘Have you ever been treated badly by friends?’ (χ2[1] = 29.05, P <0.01). Despite these indicators of more negative experiences, transgender and gender diverse participants were significantly less likely than cisgender participants to report that those around them refused to accept their sexuality or believed it did not exist (χ2[1] = 16.92, P <0.01), and participation in LGBTI community events was markedly higher for transgender and gender diverse participants than cisgender participants (χ2[1] = 64.79, P <0.01).
Discussion
This study supports the findings of previous research reporting very high rates of poor mental health among transgender and gender diverse bisexual people.8 Seventy-two per cent of transgender and gender diverse participants reported high or very high levels of psychological distress, a figure that is substantially higher than the Australian national average of 12%.17 Transgender and gender diverse ‘Who I Am’ participants were significantly more likely to report high psychological distress than their cisgender bisexual counterparts. K10 scores among transgender and gender diverse participants in this study were also substantially higher than those reported in a previous study of the Australian LGBT community,5 in which the average K10 score was 19.65, compared with 27.09 for transgender and gender diverse participants in this study. Very high rates of suicidality were found among this sample, with 92% of transgender and gender diverse bisexual participants having considered suicide, while almost one in two had attempted suicide. This is alarmingly higher than the reported figures in an Australian population-based study in which 13% had considered suicide and 3% had attempted suicide.18
A significant discrepancy was found between respondents reporting thinking they have had, or currently have, a mental health disorder and having received a diagnosis of a mental health disorder by a health professional. For example, while 70% of the sample reported being told by a health professional that they have depression, only 31% reported thinking they had had depression in the past, and 24% currently thought they were depressed. Previous research has found that those in minority groups (such as ethnic minorities) are more likely to experience overdiagnosis and misdiagnosis of mental disorders.19,20 Further research is needed to better understand if transgender and gender diverse people are more vulnerable than cisgender people to overdiagnosis of mental health conditions and, if so, the possible drivers of this, such as misunderstanding or lack of experience among health professionals in working with these populations.
In the current study, transgender and gender diverse participants reported experiences of biphobia with significantly greater frequency than cisgender respondents, although they did not report a greater sense of internalised biphobia or self-negativity. It is possible that transgender and gender diverse people experience negative responses to their sexuality as a result of their gender presentation. In other words, transphobia may make people more vulnerable to other forms of stigma and discrimination, including against their sexuality.21
The findings of this study suggest that factors that support mental health among transgender and gender diverse population include increasing visibility of transgender and gender diverse people in the general community, being ‘out’ about their sexuality, and being connected to LGBTI communities. Past research has reported a link between bisexual people’s experiences of bi-invisibility and poorer mental health.22 However, this was not the case for transgender and gender diverse people in the present sample. A sense of invisibility was not found to correlate with greater psychological distress. The recent ‘trans movement’ has, in the past decade, significantly increased the visibility of transgender and gender diverse people.3 Eisner notes that this can be seen as a learning opportunity for the bisexual community regarding how to raise the profile, and therefore visibility, of a population that falls outside of socially accepted sex and gender dichotomies.3 It is possible that transgender and gender diverse participants are experiencing some mental health benefits from this greater visibility and acceptance. In addition, being ‘out’ to others about their sexuality is much less common for bisexual people than for other sexual orientation groups, something that has been associated with poorer mental wellbeing.3,5,22 However, previous research has found that transgender and gender diverse people are more likely to be ‘out’ about their sexuality than their cisgender counterparts.23 It is possible that this has also provided some buffer against poorer mental health for transgender and gender diverse people in this sample. Further, the present study found that, for transgender and gender diverse participants, being involved in LGBTI community events supported better mental health. This is consistent with previous Australian research,5 which found a clear link between higher levels of connection to LGBTI communities and better mental health in gender diverse people.5,24 In the ‘Who I Am’ study, transgender and gender diverse participants reported significantly higher rates of participation in LGBTI community events than cisgender participants.
Some limitations were present in this study. Despite a broad recruitment strategy, the vast majority of participants were recruited online via Facebook and email networks. Therefore, people who were not connected via either of these platforms had limited exposure to advertising. As a result of the use of convenience sampling, the findings presented in this paper may not be representative of the broader transgender and gender diverse bisexual population in Australia. Only recruiting bisexual people may be seen as a limitation, as no ‘non-bisexual’ control group was able to be included in the analysis. As a result of the survey relying on self-reporting and participants’ ability to choose to skip questions they did not want to answer, reporting bias and missing data could be a limitation. Furthermore, participants were asked about whether they thought they had a mental illness; this ‘self-diagnosis’ has inherent limitations.
The ‘Who I Am’ study is the largest study of bisexual Australians to date, involving an unprecedented number of transgender and gender diverse bisexual people. Findings show that transgender and gender diverse bisexual people experience very high rates of psychological distress, mental disorders and suicidality. This was linked to experiences of biphobia, internalised biphobia, a sense of erasure of their sexuality by others, and less engagement in LGBTI community events. It is important that general practitioners (GPs) and others involved in mental healthcare are aware that both bisexuality and gender diversity may create vulnerabilities for individuals with regard to their mental health. Better understanding of the social factors and life experiences that enhance vulnerability to, or act as a buffer against, poorer mental health within these populations will improve care of people from these populations.
Implications for general practice
For the bisexual population, as for the broader population, GPs are a key first point of contact for mental healthcare. This study reports:
- transgender and gender diverse bisexual people experience very high rates of psychological distress and attempted suicide
- increased internalised biphobia (negative feelings about one’s own sexuality) and less participation in LGBTI community events was predictive of poor mental health
- there are marked differences between cisgender bisexual people and transgender and gender diverse bisexual people with regard to mental health and social experiences associated with it.
These findings provide rare insights into a vulnerable group of people currently under-identified, under-researched and under-serviced. As frontline clinicians in mental healthcare, GPs require up-to-date information that can inform their practice with this high-risk group.
Suggested questions for general practitioners
These questions may be helpful as a starting point for practitioners when asking their patients about their gender and/or sexuality:
- How do you describe your gender?
- Are you currently sexually active? If yes, what is the gender of your partner/s?
It is important not to guess or make judgements about a patient’s gender or sexuality on the basis of how they present or what relationship they appear to be in. Making no assumptions and using open, non-judgemental questions allows patients to define themselves, which can assist clinicians to more accurately assess mental health risk factors.