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Examining victimization and psychological distress in transgender college students.

Treatment-seeking and non-treatment-seeking transgender college students were examined with regard to victimization and psychological distress. Findings showed that transgender college students had elevated rates of distress as compared with college students who identified as men or women. Results indicated that treatment-seeking and non-treatment-seeking transgender college students did not significantly differ with regard to psychological distress or experiences of victimization, with the exception of rates of suicidal ideation.

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The recent Campus Pride National Campus Climate Survey (Rankin, Weber, Blumenfeld, & Frazer, 2010) explored lesbian, gay, bisexual, and transgender (LGBT) college students experiences of campus climate at colleges and universities across the United States. Findings supported previous research (Dolan, 1998; Noack, 2004; Rankin, 2003), indicating that LGBT individuals continued to experience a "chilly" or hostile campus climate. Notably, transgender students in the Rankin et al. (2010) survey reported higher rates of harassment than did men or women in the sample, and they attributed this harassment to their gender identity. Transgender students were also more likely than students who identified as men or women to have had negative perceptions of campus climate, considered leaving their college, feared for their safety because of their gender identity, and avoided disclosing their gender identity because they feared negative consequences and intimidation (Rankin et al., 2010). These data are consistent with previous empirical research that suggests that transgender individuals' experiences with violence and discrimination have increased over the past decade (e.g., Clements-Nolle, Marx, & Katz, 2006; Kenagy, 2005; Lombardi, Wilchins, Priesing, & Malouf, 2001). With the exception of the Rankin et al. study, however, most of the existing research has focused on the adult transgender population. Little empirical attention has been paid specifically to the experiences of transgender college students, despite anecdotal evidence that indicates an increase in the number of students who identify as transgender or report questioning their gender identity (e.g., Beemyn, 2003; Carter, 2000; Lees, 1998). These findings highlight the importance of expanding understanding of this population and the psychological impact of the harassment faced by transgender students.

Terminology

Transgender is an inclusive "umbrella" term that encompasses a broad range of individuals whose gender identity and expression do not match the traditional gender norms assigned to their sex at birth (Carroll, Gilroy, & Ryan, 2002; Feinberg, 1998). Transgender individuals can be considered gender-transgressive in that they express their gender identity in ways that are not considered socially acceptable or appropriate based on their biological sex (Fassinger & Arseneau, 2007). The ways that transgender individuals express their gender are varied and range from mannerisms and dress to surgical interventions and hormonal treatments (Fassinger & Arseneau, 2007). Individuals who identify as transgender may more specifically identify, for example, as transsexuals, transvestites, bigender people, cross-dressers, or gender queers. Anecdotally, transgender individuals are thought to frequently encounter gender-related discrimination, prejudice, or violence that stems from negative attitudes toward persons who do not subscribe to traditional gender norms (Lev, 2004).

Minority Stress Theory

Minority stress theory can provide a framework for understanding the impact of external stressors, like discrimination, on transgender individuals (Meyer, 1995, 2003). Originally developed to account for the unique stressors that minority individuals experience because of their membership in a socially stigmatized group, minority stress theory posits that the increased stress faced by minority individuals leads to an increased level of psychological distress when individuals are unable to successfully increase their level of coping. Meyer (2003) defined two types of stressors: distal and proximal. Meyer asserted that distal stressors are objective stressors external to the individual, such as violence and discrimination. Minority stress theory and recent empirical research indicate that the transgender population, including the transgender college student population, is at high risk of experiencing distal stressors, because this population faces elevated rates of both violence (e.g., Kenagy, 2005) and discrimination (Clements-Nolle et al., 2006; Rankin et al., 2010). Furthermore, minority stress theory also indicates that transgender individuals are at great risk of experiencing proximal, or internal, stressors, if they internalize the negative reactions often encountered in society. To date, however, no empirical research has directly explored transgender individuals' experiences of proximal stressors, and our study methodology limits our ability to do this as well.

Victimization and Distress in Transgender Individuals

A small number of related studies have examined nonstudent transgender individuals, and results revealed that this population has confronted consid- challenges related to societal bigotry, including drastically elevated rates of violence and discrimination (Clements-Nolle et al., 2006; Dew, 2007; Kenagy, 2005; Lombardi et al., 2001). A recent large-scale study (N = 515) of transgender individuals showed that 62% of transgender respondents experienced gender discrimination (Clements-Nolle et al., 2006). In the same study, 83% of the participants reported experiencing verbal gender victimization and 36% reported experiencing physical gender victimization. These percentages are strikingly high and comparable to other studies of this population (Kenagy, 2005; Lombardi et al., 2001). Additionally, estimates of the percentage of transgender people who have experienced rape or forced sex range from 53.8% (Kenagy, 2005) to 59% (Clements-Nolle et al., 2006). Notably, Lombardi et al. (2001) found that younger transgender people were more likely to experience violence than were older members of this group.

Minority stress theory postulates that these high rates of victimization and harassment (distal stressors) lead to increased rates of psychological distress for the affected individuals. Indeed, recent studies provide empirical support for this idea. Clements-Nolle et al. (2006) found that 32% of a large transgender sample reported attempting suicide. Kenagy (2005) reported similar results, finding that 30.1% of transgender individuals in the sample attempted suicide; of the individuals who had attempted suicide, 67.3% indicated their suicide attempt was related to their gender identity. Additionally, Mathy (2002) found that transgender individuals were more likely to attempt suicide than were heterosexual men and women and gay men. Regarding youth, a study by Grossman and D'Augelli (2007) examined suicidal ideation and attempts in transgender individuals who were between 15 and 21 years old. Results were similar to studies of transgender adults; 45% of the transgender youth reported seriously considering committing suicide, and 26% of the sample reported that they had attempted suicide. Taken together, results from the previously mentioned studies provide strong support for the idea that transgender individuals are at increased risk for serious psychological distress.

Transgender College Students

An increasing number of theoretical (e.g., Bilodeau, 2005) or policy-related articles (e.g., Beemyn, 2003, 2005; Beemyn, Curtis, Davis, & Tubbs, 2005) have addressed specific concerns of transgender college students, such as gender-exclusive policies and practices regarding residence halls, health care, and bathrooms. However, few have empirically examined this population's experiences with victimization and discrimination. As previously noted, however, the empirical research that does exist has indicated that transgender students encounter a hostile campus climate and report more discrimination than do their peers who identify as men or women (Rankin et al., 2010). The impact on transgender students' psychological health is unclear because of a lack of research in this area. Minority stress theory and the extant empirical studies regarding the transgender population support the view that transgender college students will face increased psychological distress as a result of the harassment and discrimination they encounter. The purpose of our study is to examine the harassment and discrimination against, as well as the psychological health of, transgender college students, using both treatment-seeking (clinical) and non-treatment-seeking (nonclinical) populations. We hypothesized that treatment-seeking and non-treatment-seeking transgender college students would be similar in terms of their rates of victimization and levels of psychological distress. We also hypothesized that college students who identified as transgender would report higher rates of victimization and psychological distress than would college students who identified as either a man or a woman.

Method

A description of our two samples follows. As reflected in an article by Hayes, Locke, and Castonguay (2011; this issue), the first sample comprises students from the general campus population surveyed by Student Affairs Administrators in Higher Education (NASPA). The second sample comprises college students seeking counseling services at one of 66 counseling centers nationwide that contributed data to the Center for Collegiate Mental Health (CCMH). In the lead article of this special edition, more details are provided about how these data were collected (see Hayes et al., 2011).

Nonclinical Participants

All participants in this study were asked to indicate their gender identity. Of the 21,686 included in this random national sample of college students, 7,191 (35%) identified as a man; 13,244 (61%) identified as a woman; 29 (.1%) identified as transgender; and 57 (.3%) endorsed the term other. Within the transgender community, there is tremendous debate about terminology and resistance to categorization (Lev, 2004), with many individuals eschewing the term transgender. Furthermore, although participants in the "other" group did not choose to identify as transgender, they also elected not to endorse either man or woman, an indication that none of the options for gender identity were appropriate. These students clearly did not wish to identify as a man or a woman, and it may be that the specific term with which they identified (e.g., transsexual, bigender) was not provided as an answer option. Thus, we were interested in combining the transgender and other groups. To assess these groups in terms of rates of victimization and distress and to ensure that they were not, in fact, different, we performed a series of chi-square analyses on five dependent variables: self-injurious behavior; suicidal ideation; suicide attempt; experiencing unwanted sexual contact; and experiencing harassing, controlling, or abusive behavior. First, data were transformed from categorical variables indicating if and when a behavior occurred (i.e., never, prior to college, after starting college, or both) to dichotomous variables indicating whether or not the behavior occurred (i.e., yes or no). The sole independent variable was identified gender identity (transgender or other). All five chi-square analyses failed to find significant differences between these two groups. Students who identified as transgender did not differ from students who selected other in reported rates of self-injury, [chi square](1, N= 70) = .014, p = .904; suicidal ideation, [chi square](1, N= 71) = .430, p = .512; attempted suicide, [chi square] (1, N= 70) = .650, p = .420; unwanted sexual contact, [chi square] (1, N= 67) = .074, p = .786; or experiencing harassing, controlling, or abusive behavior, [chi square] (1, N= 68) = 1.065, p = .302. Given our theoretical rationale for combining these groups, as well as our findings that the groups did not differ in terms of distress or victimization, we decided to combine the transgender and other groups for the purpose of this study and this sample. Thus, our final sample size for the non-clinical sample was 86 participants.

Given that one of the purposes of this study was to compare the experiences of individuals showing discomfort with traditional gender identities and were currently in treatment with those who were not, we began by examining the sample's treatment-seeking characteristics. As noted in the Hayes et al. (2011) article, participants included in this population were a sample of general college students. Some of the students included in this sample indicated that they were currently seeking treatment; thus, we removed them from our sample to ensure that the transgender students in this sample were not currently seeking treatment. Of the 86 participants, 10 were currently in some form of mental health treatment on campus and seven were seeking mental health treatment off campus. One person did not answer this question. Although it considerably decreased the size of our sample, we decided to focus on the 68 participants who indicated that they were currently not in treatment. It should be noted that although these participants indicated that they were not currently in treatment, some participants indicated having had previous mental health treatment experience. Thirty-seven (54%) indicated having attended counseling previously, seven (10%) had been hospitalized for mental health concerns, five (7.5%) indicated that they had received treatment for alcohol or drug use, and three (4.4%) were currently taking medication for a mental health concern.

The average age of participants was 22 years (SD = 9.52). Twelve (18%) participants self-identified as 1st-year students, 12 (18%) as sophomores, 19 (28%) as juniors, 17 (25%) as seniors, three (4.4%) as graduate students, and five (7%) as other. When asked to identify their preferred racial designation, 29 (43%) indicated that they were White/Caucasian, five (7%) were multiracial, three (4%) were Middle Eastern, two (3%) were Asian/Pacific Islander, two (3%) were Black/African American, two (3%) were Latino(a)/Hispanic, two (3%) were indigenous/Native American, and 23 (34%) chose not to answer. Regarding sexual orientation, 13 (19%) indicated that they were queer, 12 (18%) were heterosexual, 12 (18%) were bisexual, five (7%) were asexual, five (7%) were gay, seven (10%) were lesbian, five (7%) were questioning, two (3%) indicated other, and seven (10%) selected prefer not to answer.

Instruments

Participants in this sample responded to the 62-item Counseling Center Assessment of Psychological Symptoms (CCAPS-62; Locke et al., 2011) and the Standardized Data Set (SDS) questionnaire. For more information about the CCAPS-62 and the SDS, please refer to the introductory article to this special issue (Hayes et al., 2011). Detailed information about the CCAPS-62, including information about reliability and validity, as well as the integrity of the subscales, can be found in the article by Locke et al. (2011).

The SDS, in addition to collecting demographic information about participants, also contains questions about the participant's mental health history. Several questions elicit participants' responses regarding their behavior (e.g., "Please indicate if and when you have had the following experiences: made a suicide attempt"). Participants can select from one of the following mutually exclusive options: never, prior to college, after starting college, or both. Relative to the SDS, this study focused on the questions pertaining to distress and victimization.

Clinical Participants

Participants in the clinical sample were 27,616 college students who sought counseling services at one of 66 CCMH counseling centers. A total of 9,141 (35.4%) participants identified as male; 16,615 (64.3%) participants identified as female; and 46 (.2%) participants preferred not to answer. A total of 40 (.2%) students identified as transgender. It is important to note, however, that not all counseling centers chose to include prefer not to answer as a response option. Additionally, unlike the nonclinical sample, other was not a response option and gender identity options were listed as male and female, instead of man and woman. For the purposes of consistency and readability, we chose to use the terms man and woman throughout the current article instead of alternating between male and man and female and woman. We acknowledge that these terms may be conceptualized differently and address this concern in the Discussion section of this article.

The average age of the transgender participants was 24 years (SD = 5.6). Four (10.0%) participants identified as 1st-year students, six (15.0%) as sophomores, 12 (30.0%) as juniors, nine (22.5%) as seniors, and nine (22.5%) as graduate or professional students. Thirty students (72.5%) identified as White/Caucasian, two (5.0%) as multiracial, two (5.0%) as African American/Black, one (2.5%) as Asian American/Asian, one (2.5%) as Native Hawaiian, four (10.0%) as other, and one (2.5%) student preferred not to answer. Regarding sexual orientation, seven (17.5%) of the transgender participants identified as bisexual, six (15.0%) as gay, five (12.5%) as heterosexual, two (5.0%) as lesbian, two (5.0%) as questioning, and 11 (27.5%) indicated that they preferred not to answer. A total of seven (17.5%) participants did not respond to the question about sexual orientation.

Instruments

All participants in the clinical sample completed both the 70-item CCAPS (CCAPS-70; Locke et al., 2011) and the SDS questionnaire prior to their first counseling session. The CCAPS-70 was scored using the scoring system for the CCAPS-62. As the names might suggest, the CCAPS-62 has 62 items in common with its predecessor, the CCAPS-70. Eight items were eliminated through factor analysis because of item overlap, vague wording, and poor clinical utility. In addition, items associated with the Spirituality subscale were eliminated because of problems with clinical and empirical interpretation. The subscales for the CCAPS-62 and the CCAPS-70 are highly correlated, r [greater than or equal to] .90 or higher, given the substantial item overlap. (Readers are referred to Locke et al., 2011, for more details about the development of the CCAPS.) For further description of the CCAPS-70, including validity and reliability data for the CCAPS, please refer to the introductory article to this special issue (Hayes et al., 2011) and to Locke et al. (2011).

Results

Study I

First, we sought to determine if there were significant differences between the previously described clinical and nonclinical samples of transgender students with regard to reports of distress (i.e., self-injurious behavior, suicidal ideation, suicide attempt) and victimization (i.e., experiencing unwanted sexual contact, and experiencing harassing, controlling, or abusive behavior).

Prior to analysis, data regarding distress and victimization were examined for missing values and fit between their distributions and the assumptions of multivariate analysis. A total of seven participants from the clinical sample and three participants from the nonclinical sample were removed from analysis because of incomplete or missing data for the examined questions. No outliers were identified with regard to SDS questions about distress and victimization. A total of 32 clinical cases and 65 nonclinical cases remained for analysis.

A series of chi-square analyses were performed on three dependent variables examining distress (i.e., self-injurious behavior, suicidal ideation, and suicide attempt) and two dependent variables examining victimization (i.e., experiencing unwanted sexual contact, and experiencing harassing, controlling, or abusive behavior). To prepare data for the analysis, we transformed the data from categorical variables indicating if and when a behavior occurred (i.e., never, prior to college, after starting college, or both) to dichotomous variables indicating whether the behavior occurred (i.e., yes or no). The sole independent variable was clinical status (clinical or nonclinical).

Distress. With regard to distress, transgender college students did not differ by clinical status in reported rates of self-injury, [chi square] (1, N = 95) = 2.56, p = .110, or attempted suicide, [chi square] (1, N = 95) = .326, p = .568. However, the percentage of transgender students who reported suicidal ideation did differ by clinical status, [chi square] (1, N = 96) = 4.453, p = .035, with treatment-seeking transgender college students reporting greater rates of suicidal ideation.

More than twice as many participants who identified as transgender (42.6%) than participants who identified as men or women reported engaging in self-injurious behavior. A total of 21.3% of students who identified as men or women in the clinical sample and 16.2% of participants who identified as men or women in the nonclinical sample indicated that they had self-injured. Thirty (28.8%) transgender participants indicated that that they had engaged in this behavior prior to college, three (2.9%) participants indicated that they engaged in this behavior after starting college, and 15 (14.4%) reported that they engaged in this behavior both before and after starting college.

With regard to whether participants had attempted suicide, more than 3 times as many participants who identified as transgender, as compared to participants who identified as men or women, reported a suicide attempt. A total of 27 (25.7%) transgender students reported making a suicide attempt, compared with 8.4% of students who identified as men or women in the clinical sample and 4.9% of students who identified as men or women in the nonclinical sample. Thirteen (13.4 %) transgender participants indicated that they made a suicide attempt prior to college, five (4.8%) reported attempting suicide after starting college, and nine (8.6%) reported attempting suicide both prior to and after starting college.

Rates of reported suicidal ideation differed significantly by sample. In the clinical sample, more than half of the participants who identified as transgender--more than twice as many participants who identified as men or women--reported seriously considering suicide. A total of 31(62.2%) transgender students reported that they had seriously considered suicide, compared to 24.7% of participants who identified as men or women. Twelve (32.4%) transgender participants reported seriously considering suicide prior to college, six (16.2%) reported seriously considering suicide after starting college, and five (13.5%) reported that they seriously considered suicide both prior to and after starting college. In the nonclinical sample, less than half of the students who identified as transgender (42.6%) reported seriously considering suicide, compared with 16.2% of participants who identified as men or women. Eleven (62.2%) transgender students reported seriously considering suicide prior to college, six (8.8%) reported seriously considering suicide after starting college, and 12 (17.6%) reported seriously considering suicide both prior to and after starting college.

Victimization. Two SDS questions regarding victimization were examined; specifically, questions about unwanted sexual contact and experiences of harassing, controlling, and abusive behavior were explored. With regard to victimization, students did not differ by clinical status in reported rates of unwanted sexual contact, [chi square](1, N= 93) = .047, p = .829, or rates of experiencing harassing, controlling, or abusive behavior, [chi square](1, N = 91) = .450, p = .502.

Participants who identified as transgender were more than 1.5 times more likely to report unwanted sexual contacts or experiences than were participants who identified as men or women in either sample. A total of 36 (35.3%) participants who identified as transgender indicated that they had unwanted sexual contacts or experiences, compared with 21.3% of students who identified as men or women in the clinical sample and 20.7% of students who identified as men or women in the nonclinical sample. Eighteen (17.6%) transgender students reported that they had an unwanted sexual contact or experience prior to college, 12 (11.8%) students reported that they had this experience after starting college, and six (5.9%) transgender participants reported unwanted sexual contacts or experiences both prior to and after starting college.

Similar to the just described question, students who identified as transgender were approximately 1.5 times more likely than students who identified as men or women to report experiencing harassing, controlling, or abusive behavior. Fifty-three (53%) participants who identified as transgender reported that they had experienced harassing, controlling, or abusive behavior from another person, compared with 35% of students who identified as men or women in the clinical sample and 31% of students who identified as men or women in the nonclinical sample who endorsed this item. Twenty (20%) transgender participants reported having this experience prior to college, nine (9%) reported having this experience after starting college, and 24 (24.0%) reported experiencing these types of behaviors both prior to and after starting college.

Overall, consistent with prior empirical findings about the general transgender population, results indicate that transgender college students experienced both victimization and distress related to self-injury, suicidal ideation, and suicide attempt at much greater rates than did participants who identified as men or women.

Study 2

Next, we sought to examine data from both the clinical and nonclinical samples with regard to subscale scores on the CCAPS. Specifically, we were interested in determining if there were any differences between participants who identified as transgender and participants who identified as a man or woman in the respective samples, and if any significant differences existed between these samples in terms of scores on the CCAPS subscales. It is important to note that only 29 of the 40 transgender participants in the clinical sample completed the CCAPS because not every CCMH counseling center chose to administer this measure during the pilot study.

Table 1 displays the means and standard deviations for each of the CCAPS subscales for both the clinical and the nonclinical samples. As shown in the table, there were vast differences in sample size for each cell, and, thus, we were unable to use more sophisticated analyses to determine whether the rates of psychological distress for transgender participants were significantly different from those of their respective norm group. With regard to the nonclinical sample, noteworthy observed mean differences occurred with regard to two subscales on the CCAPS-62 (i.e., Generalized Anxiety, Family Distress). On both subscales, the transgender participants (n = 68) achieved scores at least a half point higher than men did (n = 6,466). For the clinical sample, only one noteworthy observed mean difference occurred with regard to the Family Distress subscale on the CCAPS-70. Transgender participants (n = 29) achieved scores at least a half point higher than did participants who identified as men (n = 6,283). There were no incidences in either sample where participants who identified as transgender scored a half point lower than did participants who identified as a man or woman.

We wanted to explore whether the distress evidenced by transgender participants in the nonclinical sample differed significantly from distress evidenced by transgender participants in the clinical population. As can be seen in Table 1, on almost every subscale of the CCAPS, transgender participants in the clinical sample scored less than half a point higher than did transgender participants in the nonclinical sample. We first attempted to use multivariate analysis of variance (MANOVA) to investigate whether the samples meaningfully differed with regard to level of distress, although we did so with some caution given that two different versions of the CCAPS were used and our sample sizes were unequal, with the nonclinical sample (n = 68) more than twice the size of the clinical sample (n = 29). Given evidence that the data did not fully meet the assumptions for MANOVA with regard to homogeneity of covariance matrices and our unwillingness to delete cases to equalize sample size, we chose to run a series of t tests, with equal variances not assumed, to investigate mean differences. Consistent with our observations, none of the mean differences achieved significance (p > .05). Thus, these findings suggest that transgender students, whether or not they are seeking psychological treatment, report equivalent levels of distress.

Discussion

The purpose of conducting this study was to examine rates of victimization and psychological distress in treatment-seeking and non-treatment-seeking populations of transgender college students. Support was found for the hypothesis that treatment-seeking and non treatment-seeking transgender college students would be similar with regard to their rates of victimization and levels of psychological distress. Also, support was found for the hypothesis that college students who identify as transgender would report higher rates of victimization and psychological distress than would students who identify as men or women with regard to SDS questions. To our knowledge, this is the first quantitative study to specifically examine both treatment-seeking and non-treatment-seeking transgender college students with regard to victimization and psychological distress.

Both samples were diverse relative to race/ethnicity and sexual orientation. A small percentage of transgender participants identified as heterosexual, but the majority identified as sexual minorities, providing evidence that transgender students tend to be in the minority with regard to both gender and sexual identity. Race/ethnicity was more difficult to categorize given the large number of participants who chose not to answer this question. The race/ ethnicity most frequently endorsed by participants was White/Caucasian, but approximately 25% of the participants identified as non-White. The majority of transgender students identified as juniors or seniors; perhaps individuals are more likely to acknowledge a nontraditional gender identity as they grow older. College is often a time when individuals explore parts of their identity, and it seems reasonable to assume that exploration and disclosure of gender identity is part of this process.

Implications for Practice

Our findings indicated that transgender college students were universally distressed, regardless of whether they were treatment seekers. Transgender college students experienced distress at rates that were overwhelmingly higher than those for students with a traditional gender identity (men and women). Results indicated striking differences between students who identified as men or women and students who identified as transgender with regard to SDS questions about self-injury, suicidal ideation, and suicide attempt. Perhaps most alarming was the finding that rates of self-injury and suicide attempt were not significantly different in the clinical and nonclinical samples. It is interesting that treatment-seeking and non-treatment-seeking participants differed with regard to rates of reported suicidal ideation, with treatment-seeking transgender students reporting significantly higher rates of suicidal ideation. This begs the question of whether experiencing suicidal thoughts leads transgender students to seek treatment. Perhaps reaching this level of distress motivates students to seek psychological support.

Additionally, participants' scores on the subscales of the CCAPS were not significantly different by sample origin. Individuals in the clinical sample sought professional help, but it is not clear if and how participants in the nonclinical sample were successfully coping with such high levels of distress. Previous research by McKinney (2005) indicated that transgender college students may be reluctant to seek counseling services, reporting that they were not comfortable discussing their gender identity with counseling center clinicians, had heard from peers that clinicians on their campus were not knowledgeable about issues affecting transgender students, or were concerned about being diagnosed with a gender identity disorder. It is important for counseling center clinicians to be aware of both the level of distress experienced by transgender students on campus and the reluctance such individuals may feel about seeking counseling.

In addition to elevated rates of distress, students who identified as transgender in both samples reported higher rates of victimization than did students who identified as men or women. Although we cannot conclude that these increased rates of victimization led to or caused the high rates of distress in transgender students, we are curious about the connection. Minority stress theory (Meyer, 1995, 2003) posits that the distal stressors minority individuals often face, such as unwanted sexual contact or harassing or abusive behavior, lead to increased levels of psychological distress when the individuals are unsuccessful in their efforts to increase their level of coping. This theory can provide a context for our findings. Again, awareness of the increased rates of victimization experienced by transgender individuals can facilitate counselors' attention to such issues when working with transgender clients.

Limitations and Directions for Future Research

There are several notable limitations to our study. First, study participants were asked to respond to the question about gender by choosing among narrow options. In the clinical sample, participants were able to select only one of the following options: male, female, transgender, or prefer not to answer. In the nonclinical sample, participants had to choose one of the following options: man, woman, transgender, or other. With regard to language, we recognize that possible answers for this question were not the same in each sample (i.e., male vs. man, female vs. woman). Although these terms are often used interchangeably and conflated, the terms male and female are most appropriate when describing birth sex, whereas the terms man and woman are most appropriate when describing gender identity. These terms, therefore, are not synonymous. We chose, however, to use the terms men and women to reflect our intention of focusing on gender identity rather than biological sex. We acknowledge that using the terms male and female in the clinical sample was indeed a limitation, because they do not capture gender identity in the same way that the terms man and woman do. Additionally, we recognize that transgender is an umbrella term and that individuals may not want to identify with such a term, preferring a different or more specific gender identity (e.g., gender queer, transvestite). Thus, the way we asked about gender, particularly in the clinical sample, may have limited responses. Second, we had a relatively small sample size. We suspect that there are many more transgender students on campus who were not represented in our sample; we were limited by the data collection methods, which were not specifically designed to tap into the transgender population. Third, we used two different versions of the CCAPS (CCAPS-62 and CCAPS-70), as discussed in the Method section of this article. Although the correlation between the two versions was very high, it is important to acknowledge that the measures were not exactly the same for both samples.

Our study is unique in that it used data collected from numerous colleges and universities across the United States. Participants did not simply come from one type of college or one area of the country but were representative of numerous colleges and geographic areas. The structure of the CCMH, a practice--research network dedicated to better understanding the psychological needs of college students, allowed us to gather such a sample. Furthermore, this is one of very few studies that examine the experiences of transgender college students with respect to both victimization and psychological distress and the first, to our knowledge, to specifically examine the experiences of treatment-seeking transgender college students. Given the recent report on campus climate by Rankin et al. (2010), which described the numerous struggles faced by this population, more studies are needed to understand the broader experiences of transgender college students.

Further research should focus on more directly examining the link between victimization and distress in transgender college students. Larger sample sizes would allow for more robust findings and sophisticated statistical analyses. Additionally, it is essential to better understand why some transgender students are not utilizing college counseling services. Clearly, these individuals report high rates of serious psychological distress, including self-injurious behavior and suicidal ideation. Understanding these students' reasons for not attending treatment may help inform programmatic interventions aimed at helping this population cope with distress.

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Jessica C. Effrig and Kathleen J. Bieschke, Counseling Psychology Program, and Benjamin D. Locke, Center for Counseling and Psychological Services, Pennsylvania State University. Correspondence concerning this article should be addressed to Jessica C. Effrig, Counseling Psychology Program, Pennsylvania State University, 327 CEDAR Building, University Park, PA 16802 (e-mail: jcs307@psu.edu).
TABLE 1
Means and Standard Deviations for Counseling Center
Assessment of Psychological Symptoms (CCAPS) Subscales
by Gender and Sample

CCAPS Subscale          Clinical Sample    Nonclinical Sample

                           M      SD          M      SD
Depression
  Men                     1.44   0.94        0.80   0.74
  Women                   1.66   0.92        0.83   0.74
  Transgender             1.47   0.83        1.18   1.06
Eating Concerns
  Men                     0.69   0.69        0.76   0.68
  Women                   1.16   0.95        1.13   0.85
  Transgender             0.83   0.67        0.95   0.95
Substance Use
  Men                     0.86   0.89        0.82   0.89
  Women                   0.68   0.83        0.63   0.80
  Transgender             0.53   0.75        0.82   1.16
Generalized Anxiety
  Men                     1.35   0.88        0.87   0.68
  Women                   1.69   0.91        1.07   0.77
  Transgender             1.55   0.90        1.37   1.04
Hostility
  Men                     1.00   0.88        0.70   0.70
  Women                   1.01   0.85        0.63   0.68
  Transgender             1.23   1.11        1.03   1.05
Social Anxiety
  Men                     1.72   0.96        1.46   0.84
  Women                   1.83   0.92        1.55   0.84
  Transgender             1.64   0.93        1.61   0.87
Family Distress
  Men                     1.08   0.89        0.70   0.71
  Women                   1.29   0.96        0.82   0.79
  Transgender             1.66   1.26        1.34   0.99
Academic Distress
  Men                     1.84   1.03        1.24   0.84
  Women                   1.90   1.03        1.22   0.84
  Transgender             1.52   0.79        1.44   0.99

Note. Participants in the clinical sample completed the
70-item CCAPS, whereas participants in the nonclinical sample
completed the 62-item CCAPS.
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Title Annotation:Research
Author:Effrig, Jessica C.; Bieschke, Kathleen J.; Locke, Benjamin D.
Publication:Journal of College Counseling
Article Type:Report
Geographic Code:1USA
Date:Sep 22, 2011
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