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“Growing up, there was nothing out there or at least I didn’t know of anything, and I didn’t know how to look for it. It was very isolating”, recalls Robin Zlatarev, lead coordinator of the trans programme at the Bulgarian Bilitis Foundation. “As a teenager, I suffered from anxiety and depression, partly because of my dysphoria, but also due to a lack of understanding and visibility.” The journey was long and difficult for Zlatarev, who identifies as non-binary. It has been ten years since he came to terms with who he is. In that same time, he believes, “the hatred has only intensified”.
In Bulgaria, transgender and non-binary people who are victims of such hatred are generally left to fend for themselves. Their care therefore ends up falling to citizen groups. Zlatarev believes that support should focus on two aspects. “There should be communities and spaces where people can gather, connect, discuss their experiences, and at the same time have qualified professionals working with them.” Zlatarev argues that the situation in Bulgaria is particularly difficult for trans people, who find themselves the target of moral panic.
The only positive factor, says Zlatarev, is the easier access to information today. Yet this transparency contrasts with a certain lack of statistics. There are no official figures assessing the mental health of Bulgaria’s transgender people, or even their numbers.
In 2023, Bulgaria's highest court of appeal handed down a ruling stating that gender should be understood solely in its biological sense. For those concerned, this ruled out the possibility of legal recognition of their gender for those concerned, something that had previously been available to them. It therefore represents a clear step backwards for the law, with direct consequences: individuals may be unable to travel or to access healthcare if there is a discrepancy between their physical appearance and the gender marker recorded on their identity documents.
The uncertain consequences of transphobia
It is hard to quantify the number of transgender people in Europe, since estimates and counting methods vary from country to country. As for the health consequences of transphobia, some preliminary insights are offered by a 2022 study in the Journal of Psychopathology, which involved 47 transgender and 47 cisgender people living in Italy.
The analysis, carried out by researchers at the University of Palermo, showed that “transgender people [exhibited] significantly more pronounced abnormalities than the cisgender control group with regard to weight phobia, body-image concerns, avoidance behaviours, compulsive self-monitoring, depersonalisation [and self-esteem levels].”
Their analysis also found that transgender people reported a lower quality of life than cisgender people in sexual, psychological and relational terms. The study found no significant differences regarding physical and environmental quality of life or mental-health issues.
In 2024, the EU's Agency for Fundamental Rights (FRA) published its third report on the life experiences and discrimination faced by LGBT+ people in the bloc. Whilst all LGBT+ people, regardless of their identity, report having experienced discrimination on the basis of their identity, transgender and intersex people are particularly vulnerable.
In 2023, 54% and 61% of them, respectively, said they had been discriminated against in at least one area of their lives because of their identity. We tend to blame trans identity for poor mental health, yet it is often transphobia that lies at the root of the problem. Experiencing transphobia also tends to be linked to a deterioration in mental health and an increase in suicidal thoughts.
The FRA report, for its part, shows that trans people are more likely to experience suicidal thoughts. 59% of trans women, 60% of trans men and 55% of non-binary people reported having thought about suicide (occasionally, often or all the time) in the year leading up to the survey. The issue of protecting these vulnerable groups from discrimination is therefore no longer just a democratic imperative. It has also become a public health concern.
In the view of psychotherapist Agnieszka Pixie Frączek, transphobia has very real consequences when it occurs among individuals or institutions that are supposed to defend human rights. “Authorities should shape the narrative in a pro-humanitarian direction, taking all people into account“, she warns.” If this does not happen, derogatory and devaluing language begins to be permitted and used widely.” In Poland, where Agnieszka Pixie Frączek works, conservative politicians such as Jarosław Kaczyński and Andrzej Duda (a former president and former prime minister of Poland) regularly make derisive or reductive comments about LGBT+ minorities, and particularly about trans people.
A particular understanding of mental health
Having one’s existence and right to healthcare recognised is no guarantee of escaping transphobia. Sandra Konstatzky, director of Austria’s Office for Equal Treatment (GAW), has sounded the alarm about discrimination in healthcare settings in Austria. She says she has received several complaints regarding instances of discrimination or inappropriate behaviour during medical appointments. Transgender people who experience degrading treatment, a refusal of care, or intrusive questions have few legal avenues to challenge such behaviour.
For Konstatzky, the problems are particularly serious in the areas of sexual and mental health, and pathologisation during an examination is a real hazard. Cases have been reported in which transgender patients seeking a consultation were encouraged to reconsider or suppress their identity rather than receiving supportive care.
In debates on gender issues, there is a constant danger of pathologising transgender identities and reducing them to mere consequences of pre-existing psychological problems in need of treatment
Technically, since 2009, trans people in Austria have not been required to undergo sterilisation or gender-affirming surgery in order to obtain legal recognition of their gender. However, recognition remains largely tied to medical or psychiatric assessments. In practice, individuals often have to obtain several expert opinions confirming a diagnosis of “gender incongruence” or “transsexualism” before their official documents can be amended. Activists argue that the effect is to keep transgender identities subject to medical approval rather than to respect an individual’s self-determination.
But the recognition of gender identities and the issue of mental health are not confined to doctors’ surgeries and legal texts. In debates on gender issues, there is a constant danger of pathologising transgender identities and reducing them to mere consequences of pre-existing psychological problems in need of treatment.
Despite these issues, there has been some change over time. The term “gender dysphoria” – which describes a sense of unease caused by the incongruence between one’s gender identity and the sex assigned at birth – has replaced “gender identity disorder” in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, published in 2013). Starting in 2019, the World Health Organisation no longer regards as a “mental disorder” the fact of identifying as a transgender person. These are two signs of a shift in attitudes and a – very incomplete – depathologisation of transgender identities.
The case of the Cass report
In the face of evolving concepts, the “repathologisation” advocated by certain anti-trans critics appears to be a step backwards. Mental health, rather than being a genuine concern, becomes a rhetorical weapon – one used to undermine an individual’s right to access healthcare and legal protection. And this may be true even without intention.
“I want to make sure you receive the best combination of treatment”, promised, for example, the British doctor and paediatrician Hilary Cass to transgender people in her 2024 report on gender-related care for children and young people. Although initially intended for a British audience, the document has had an international impact, to the extent that it has been discussed in the United States, in France and in Italy.
Originally commissioned by the National Health Service, and the result of several years’ work, the report begins by expressing its – seemingly sincere – concern for the health of transgender people.
In her conclusions, Hilary Cass recommends moving away from a purely medical approach towards a more holistic one, incorporating consideration of pre-existing psychological disorders, neurodivergence and family circumstances. She raises the common concerns about mental health, but does not call for a halt to medical gender-affirming procedures.
While many British media outlets and officials welcomed the Cass report’s findings, critics highlighted numerous methodological problems marring the analysis. These voices, very much in the minority, were not enough to undermine the credibility of the Cass report, which has been brandished by “gender critical” commentators – even outside the UK – to justify their attacks on transgender people.
The “regret hypothesis”
Arnaud Alessandrin is a French sociologist and author, with expertise in LGBT+ issues. In his view, the exploitation of mental health to undermine the rights of trans people operates on two levels. The first involves conflating the syndromes that transgender people may face (stress, anxiety, suicidal thoughts) with “symptoms” – in effect, conflating the consequences of transphobia with transgender identity.
For Alessandrin, the argument boils down to: “Let’s treat the ‘real’ syndromes first, and the symptoms will disappear.” If you treat mental-health issues first, trans identity will be a thing of the past, as it is supposedly “an artificial, activist, political and social response to entirely different syndromes”, summarises Alessandrin. To explain trans identities, the finger is pointed at the excesses of feminism, a misunderstood malaise, or medical and social causes.
Alessandrin continues: “The second line of argument amounts to saying that if you encourage gender transitions, particularly amongst young people, you will damage their relationship with their bodies, and they will develop psychological disorders.”
This idea is often couched in phrases imbued with seemingly noble intentions. After all, who isn’t concerned about the physical wellbeing of young people? Even before it was directed at trans people, the slogan “Think of the children” was already being wielded against other LGBT+ people, and feminists.
But the argument struggles to obscure the reality. “All the research shows an improvement in long-term mental health if healthcare needs are met”, points out Alessandrin in regards to trans patients. “There can be no doubt any longer that conditions for young people and adults are improving.”
The risk of regretting a transition is also regularly cited. This argument does not hold water, says Alessandrin: “In the scientific literature, we see that the rate of regret regarding transition is around 1%.”
The equivalent rate is higher in fields ranging from oncology to bariatric surgery and plastic surgery, he notes. “Any hospital department with such a rate would be confident that its protocol works. But not when it comes to gender transitions.” Despite the lack of scientific evidence supporting the “regret” argument, it resonates strongly in the media.
The mental health of trans people remains a major issue. In a report written in 2022, Dr Hervé Picard and Simon Jutant (who was then active within the French trans self-help organisation Acceptess-T) are clear about the stakes. “The historical psychiatrisation of trans people’s life journeys has had an impact on trans people’s access to mental health care”, they write. “They still struggle to find ways to address their mental health without it being viewed solely through the prism of their trans identity.”
For the two authors, transgender mental health – often misunderstood – calls for tailored care that neither dismisses the need for psychological support nor reduces everything to it. In short, it means depathologising care without abandoning it.
This depathologisation has a fundamental role to play in the liberation of trans people. It can give them the freedom to decide for themselves how to navigate their transition. Beyond being a public-health issue, this is also a political issue. At stake is the self-determination of trans people. That precious prize still seems some way off.
🤝 This article was produced as part of the PULSE collaborative project, with contributions from Dimitris Angelidis (Efsyn, Greece), Lorenzo Ferrari (OBCT, Italy), Iwona Görke (Gazeta Wyborcza, Poland), Desislava Koleva (Mediapool, Bulgaria) et Flora Mory (Der Standard, Austria).
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