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Título

Epidemiological aspects of Mental Health in the Transgender Population: a bibliographic review

Fundamentação/Introdução

According to medicine, the sexual identity is determined by the biological sex, being considered as a disorder any deviation from that norm. The term transsexualism was used in the medical environment to refer to such a deviation, however, with the publication of DSM V, the term was replaced by Gender Dysphoria (DG), also distinguishing itself from the terms "transsexual" and "transgender." The latter is designated by the broad spectrum of individuals who, transiently or persistently, identify with a gender other than that of birth. While transsexual indicates an individual seeking or going through a social transition from male to female or from female to male, which in many cases also involves a somatic transition through hormonal treatment and genital surgery. Already the new term proposed: gender dysphoria would be the suffering that can accompany the incongruity between the experienced or expressed gender and the designated gender of a person. Although this incongruity does not cause discomfort in all individuals, many end up suffering if the desired physical interventions through hormones and / or surgery are not available. Meanwhile, the International Classification of Diseases 11th uses the term Gender Incongruity. This is characterized by a sharp and persistent incongruity between the experienced sex of an individual and the assigned sex, which often leads to a desire for "transition." To live and be accepted as a person of the experienced genre, through hormonal treatment, surgery or other health services to make the individual's body align as much as desired and as far as possible, with the experienced genre. On the other hand, in the social sciences, gender identity has been discussed based on the subject's relationship with himself and the social and cultural environment of which he is a part, giving importance and prominence to the construction of identity and not to the biological nature of bodies. In a broader sense, transgender (as the person with TIG is popularly known) represents individuals, both male and female, who do not identify with socially constructed cultural definitions of biological sex. Following this view, transgenders cannot be confused with homosexuality and transvestism, after all, these are identified with biological sex. In the case of homosexuals, individuals belong to their biological sex, yet they relate lovingly to samesex people. In relation to transvestism, the subject belongs to his biological sex, but makes use of clothes and props of the opposite sex with intention to feel good or by erotization. However, transgender also differs from transsexual, whose differentiation starts from the choice and / or opportunity to undergo transitional procedures, which would be physical changes, through surgeries and hormonal treatments in search of the body to which it is identified.

Objetivos

This text shows the prevalence of mental disorders in transgender individuals, based on abibliographical review about this topic.

Delineamento e Métodos

This work was carried out through a review of the literature, articles and journals of different nationalities published up to the year 2017. The following databases were used: PUBMED, SCILEO and LILACS; using key words, "depression", "transgender community", “suicide”, “violence” “mental health” and "epidemiology". In addition, the Classifications of International Classification of Diseases 11th (ICD-11) and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) were used. Thus, a recapitulation was made about the epidemiological issues involving the transgender population and the comorbidity faced in the present world, depression and its present socio-cultural aspects.

Resultados

Children and adolescents with gender dysphoria when compared to other children have extreme vulnerability to physical health, a greater tendency to mental disorders, such as depression and anxiety disorder, as well as social vulnerability such as exclusion, depression, prostitution , self-mutilation and suicide. From this perspective, depression is a syndrome characterized by a set of mood-related symptoms, which includes loss of interest or pleasure, feelings of guilt or low self-esteem, disturbed sleep, altered appetite, lack of concentration and even thoughts of death and / or suicide. International studies have shown a high prevalence of depression among trans (transgender, transsexual or transitional), with estimates varying from 21% to 55% among those identified in the female to male spectrum. In this sense, it is observed that society do not have the understanding of such a condition, as Sampaio and Coelho bring, society expects the body to externalize who you are and to what gender it belongs - male or female - through the "gender norms" that are determined, in the form of dress and behave; As a consequence, transgender individuals are socially excluded, entering into a condition of social vulnerability that brings them various problems such as transphobia, bullying, impediment of access to the labor market, contributing to marginalization, having as co-morbidities prostitution, risk of sexually transmitted diseases, in addition to several psychological problems, highlighting depression, which stems from all these factors in addition to the lack of family support. Rates of depression, suicidal ideation and suicide are higher in transgender Americans than in the general population of the United States. It was observed that the prevalence of major depression was 5 times higher than when compared to the estimates of the general population of New York. Such findings are plausible in view of the discrimination these individuals suffer. Risk factors have been identified for the risk of committing suicide, such as low self-esteem, sex work, social stigma, bullying, rejection, and abandonment. Adequate social support was provided seen as a protective factor against depression in transgender, with family support being more important than that offered by friends in the prediction of depression. However, the study points out that it is not the time that this support has been offered to the individual, but yes the degree of satisfaction with such factor. As for depression rates and anxiety disorders among the transgender population compared to the cisgenic population, the former has higher levels of depression and anxiety. Trans- men have a higher rate of anxiety, while transmis- sion has a high rate of depression. Contributing factors for this may be the fact that the levels of stress faced by those with gender dysphoria are greater than those of the homosexual population, because it is more easily accepted within society, because they involve more social space. Studies show an association between violence and increased depression among the transgender population. Transgender women suffer about 2 to 3 times more violence than non-transgender women. Physical violence was associated with suicidal ideation and attempted suicide, while sexual abuse increased the risk of substance abuse. Of the studies studied, 3 showed an association between age and depression, with younger transgenders being at greater risk of depression. Two other studies did not show any relation between these two variables. However, studies related to the abuses suffered by transgender women and the onset of depression, there was a 3 times greater association of major depression in young people (19 to 30 years), when compared to the population older age (31 to 59 years). This was explained by the resilience gained over time. A significant association was found between transgender youth and attempted suicide; on average, 40% of trans teenagers engaged in suicidal behavior throughout their lives.14 Studies have found that about 1 in 2 transgenders of both sexes have tried to kill themselves at some point, this can be triggered by violence faced by young transgender people, which also leads to abuse of substances such as heroin, cocaine, methamphetamines and opioids. Including sex work, this increases the rates of sexually transmitted diseases in this population. As for sex work, a percentage greater than 60% of transgender women studied between the ages of 15 and 24, got involved with this type of work at some point in their lives. In view of the above, analyzing the abuses related to sex work, and the outcomes in the mental health of the individual, it was noticed that the penetration in this branch was associated with the indices of depression. For, in addition to the probable physical and psychological abuse, this work entails the use of illicit substances as a way of alleviating all the stress involved. Thus, there is a higher incidence of depression in this transgender group. From this perspective, the acceptance of the family nucleus to the gender transition has been beneficial, especially for transgenders of middle age, differently from the stress generated by a divergence of the family regarding the exchange of gender, which is also a precursor of clinical pictures related to mental health. In addition, the meeting of a sexual partner and the acceptance and support of this, mostly in adulthood, regarding the transition of genders, was shown to be a protective factor against the symptoms of depression. Gender dysphoria usually does not act alone, often expressing itself concomitantly with other syndromes. There was, within the literature, a worsening relationship in individuals diagnosed with other disorders before or after the transition. Within clinical conditions, the studies bring anxiety disorders, borderline personality disorder, dissociative identity disorder and schizophrenia. These comorbidities were linked to aggravations in transgender mental health, and an increase in the onset of depressive syndromes. These are associated with decreased sexual interest, due to loss of libido, which leads to impairment in the socio-affective interaction of the individual. One of the most notable contributors to the emergence of depression in the transgendered population that stands out predominantly in a significant portion of society is discrimination based on fear and hatred, transphobia. This form of phobia was added in a greater probability of the appearance of the depressive symptomatology, being that the increase of a point in the scale of transphobia was associated with a rise of 12% in the chances of depression. Thus, those exposed to a lower degree of transphobia, that is, less related to hostile and stressful environments, full of stigmas and discrimination, were less likely to develop depressive symptoms.

Conclusões/Considerações finais

The frequent simultaneous expression of other syndromes, such as anxiety disorder and depression, in individuals with Gender Dysphoria reinforces the need for more adequate access to health services for these subjects, as well as greater social and psychological support. Many of these syndromes develop as a result of the emotional and social vulnerability to which this population is exposed. Dealing with not identifying with biological sex is, by itself, a factor that can trigger an emotional breakdown. Because of the non-family and social acceptance, the risk for the development of other syndromes becomes even greater. Based on this assumption, it is imperative that the gender identity be better discussed in the different social environments, in order to provide a greater clarification for the general population on this theme. Ignorance about this issue is one of the major factors that contribute to the non-acceptance of transgenders, both in the family and in the social sphere. The respect, understanding and support, especially family, in the process of gender transition is of fundamental importance to avoid clinical conditions related to mental health.

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Área

Clínica Médica