Gender minority stress and depressive symptoms among transfeminine and gender non-conforming individuals in China: mediating and moderating roles of coping

Cao Fang | 2023

Advisor: Arjee Restar

Research Area(s): Environmental & Occupational Health, Psychiatric Epidemiology, Social Determinants of Health

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Transgender and gender non-conforming populations in China experience disproportionately higher burdens of mental health issues such as depression compared to their cisgender counterparts. The gender minority stress and resilience model further elaborates on the original minority stress theory in an effort to understand how various experiences such as gender-based violence, discrimination and rejection impact the mental health outcomes and physical well-being of this population. This study investigates the role of three coping factors: gender minority resilience, social support, and gender-affirming hormone use, and their association between gender minority stress and depression. Methods: A cross-sectional study in 2019 recruited and collected data on a total of 277 transfeminine and gender non-conforming individuals from 9 different cities in China. Gender minority stress and resilience scores were collected using the validated Gender Minority Stress and Resilience Measure, with 45 items for gender minority stress (GMS) and 13 items for gender minority resilience (GMR). Depression was measured using the Center for Epidemiologic Studies Depression Scale (CES-D 10) short form with 10 items, previously validated among populations in Hong Kong. Social support was measured using a total of 12 items, including questions on support from family members and friends in forms of emotional and practical support. In regard to gender affirmation care use, we initially investigated both surgical procedures and gender-affirming hormones. However, given that eligibility criteria for surgical procedure in China intentionally excludes individuals with major depressive disorders, we decided to focus on hormone use as a proxy to gender-affirming care use. We then conducted complete case analyses (N = 258) using structural equation models to examine the mediating role of social support on the effects of gender minority stress on depression, with both exposure and outcome modelled as latent variables. We conducted an exploratory moderation analysis with sum-of-scores of gender minority stress, resilience, and depression scores to test for interaction between gender minority stress and resilience on its relationship with depression. Finally, we explored whether gender-affirming hormone use mediates the relationship between depression and internalized transphobia, a subconstruct of gender minority stress previously found to be associated with gender-affirming hormone use using this study data. Model fit of initial models is reported, but model alterations and re-specification were not explored, thus results are provisional. For all of our models, we adjusted for the following confounders: age (continuous), gender identity (transfeminine & gender non-conforming) and income (3 level nominal categories with 3000 RMB (Chinese currency) per interval). For convenience of interpretation, coefficients included in this abstract are all path coefficients standardized by the variance of both observed and latent variables for structural equation models. Results: As noted, given that model fit was not taken into consideration, the findings of this thesis are provisional and require further analysis. For our sample demographics, most of the participants in the study identified as transfeminine (72.1%) and 30.1% were earning less than or equal to 460 USD (3000 RMB) per month. The average CES-D score was 11.8 (out of 30) and over half (62%) would be considered at risk for clinical depression given the CES-D 10 threshold. GMR score was found to be associated with overall depression score (β =-0.411, 95% CI: -0.782 – -0.023). However, we found that GMS has an equally negative impact on one’s depression score regardless of one’s GMR score (Interaction term β = 0.000, 95% CI: -0.006 – 0.006). In our initial model, social support was found to be negatively associated with both GMS and depression in our structural models. Social support also partially mediated the association between GMS and depression in this model (Indirect effect β = 0.082, 95% CI: 0.018 – 0.154, proportion mediated = 17%). We did not find evidence for any association between hormone use and depression in our starting model (β = -0.238, 95% CI: -0.499 – 0.180) nor did we find a mediating effect of hormone use on the association between internalized transphobia and depression (β = -0.005, 95% CI: -0.011 – 0.003). Conclusion: This study highlighted the potential role of social support as a mediator between GMS and depression among transfeminine and gender non-conforming individuals in China. Given the exploratory and cross-sectional nature of the study, we were unable to make inference on the association between hormone use and future mental health outcomes. Further efforts of confirmatory analysis using this data to find a better fitting model is needed to confirm those results. We also suggest that gender minority resilience measured by the GMSR measures (community connectedness and identity pride) need to be considered under the specific legal and social environment in China when thinking about future studies or interventions in those areas. Future studies might consider various expressions of resilience, in conjunction with environmental factors, to form a comprehensive support system in helping this population with coping. The findings of this thesis, as they currently stand, should not be utilized to inform any social or policy recommendations and decisions or guide medical and public health programming efforts for this population.