Invalidation and Mental Health Among Nonbinary Individuals

Psychology of Sexual Orientation and Gender Diversity | 2024, Vol. 11, No. 3, p. 413 - 424

Invalidation and Mental Health Among Nonbinary Individuals

Kelly C. Johnson; Global Health Justice Partnership, Yale Law School, Yale University

Allen J. LeBlanc; Health Equity Institute, San Francisco State University

Curtis Dolezal; Program for the Study of LGBT Health, New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing

Anneliese A. Singh; Tulane School of Social Work, Tulane University

Walter O. Bockting; Program for the Study of LGBT Health, New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing

This study examines the experience of a unique minority stressor, gender identity invalidation (henceforth referred to as invalidation), which is defined as the refusal to accept someone’s gender identity as real or valid, among transgender and nonbinary (TNB) individuals. Data are drawn from a large and diverse sample of TNB adults who participated in a quantitative survey concerning transgender identity, minority stress, and mental health (N =302). Invalidation was assessed using a novel 17-item scale that ascertains the extent to which respondents experienced invalidation across different social contexts. On average, TNB adults in this sample report low levels of invalidation, although a minority experience it at relatively high levels. Experiences of invalidation were significantly higher among nonbinary participants when compared with their binary-trans peers. A series of multivariate regression models that control for sociodemographic factors (sex assigned at birth, race/ethnicity, education, age, and income) and well-established indicators of minority stress (felt stigma, enacted stigma) suggest that nonbinary gender identity is independently associated with poor mental health (assessed with the Global Severity Index) and that this association is mediated by invalidation. These findings suggest that invalidation, which is largely unexamined in existing research, merits greater attention as a particularly salient minority stressor influencing mental health among gender-diverse populations, nonbinary populations in particular.

Transgender; nonbinary;  minority stress; mental health; invalidation

“Transgender and nonbinary (TNB) individuals experience significantly higher rates of mental health problems in comparison to their cisgender peers… Although individuals who identify within the TNB umbrella may all have non-affirming and invalidating experiences, Johnson et al. found that invalidation experiences were pervasive among nonbinary adolescents, and they occurred across multiple social contexts… These findings suggest that invalidation may represent a unique minority stressor affecting TNB populations, with particular mental health implications for nonbinary individuals. Therefore, we sought to create a quantitative scale for the purposes of exploring gender identity invalidation and its relationship to mental health outcomes across larger samples of TNB individuals” (p. 414).

“This paper has two aims: First, we introduce a novel invalidation scale and examine its reliability and correlates by testing it among a diverse quantitative sample of 302 TNB adults. Second, we examine the potential role of invalidation in minority stress processes affecting the mental health of TNB populations. We hypothesize that nonbinary individuals experience higher levels of invalidation than binary-trans individuals (Hypothesis 1). Second, we hypothesize that nonbinary identity is associated with poor mental health (Hypothesis 2), after controlling for established minority stressors (Hypothesis 3). Finally, as illustrated in Figure 1, we hypothesize that invalidation is associated with poorer mental health (Hypothesis 4), and that experiences of invalidation mediate the relationship between nonbinary gender identity and poor mental health, net the effects for established minority stressors (Hypothesis 5), helping to explain why nonbinary populations appear to be particularly vulnerable to mental health risks caused by exposure to gender minority stress” (p. 415).

“The data for this paper were drawn from the Project AFFIRM study. Project AFFIRM is a large-scale, multimethod, and multisite study of transgender identity development, stress, and resilience across the lifespan, based in three metropolitan areas of the United States: New York City, San Francisco, and Atlanta. Project AFFIRM participants were recruited for the Project AFFIRM study through purposeful, venue-based sampling across a variety of settings (online and offline) frequented by the target population… Three rounds of quantitative data were collected, beginning in 2016/2017 for the baseline assessment, and again at 1- and 2-year follow-up” (p. 416).

“Our findings demonstrate that this novel scale demonstrated high internal consistency. Importantly, we found that nonbinary adults in our sample experienced higher rates of invalidation than binary-trans adults and that their invalidation experiences were associated with worse mental health. In addition, we found that invalidation experiences mediated the relationship between nonbinary gender identity and poor mental health, even after controlling for demographics and other established minority stressors (felt stigma and enacted stigma)” (p. 418).

“In all our analyses, we also controlled for sociodemographic variables. Income was the only sociodemographic variable found to be significant within one of our regression models predicting poor mental health. This suggests that lower socioeconomic status may be a risk factor for mental health, consistent with other studies among trans-non-binary populations” (p. 419). 

“Findings from this study suggest that gender identity invalidation should be understood as a pernicious minority stressor for TNB individuals, particularly those who are nonbinary, and clinicians may find it useful to assess for invalidation experiences in their practice (Matsuno, 2019). They may also want to consider incorporating the concept of invalidation into evidence-based gender-affirming interventions that target minority stress among LGBTQ+ populations. For example, clinicians can utilize cognitive–behavioral therapy (CBT) techniques to help clients identify maladaptive thoughts and beliefs resulting from invalidation experiences and assist them in externalizing the sources of these negative messages, as well as in developing effective coping strategies to manage negative feelings resulting from invalidation experiences. They may also help clients to recognize instances where they may be engaging in self-invalidation and help them to engage in self-validation and self-compassion practices. They may additionally consider ways to encourage clients to seek validating relationships, empowering resources, and safe spaces in their communities. Finally, clinicians can help clients better navigate the relationships and settings where they may be most likely to experience invalidation and support them to advocate for themselves. 

In addition, these findings could help clinicians to be more aware of the potential role that they and the institutions they work for may play in contributing to invalidating experiences for nonbinary clients. More comprehensive training on gender-affirming care should be provided to individual providers, and healthcare organizations should take stock of how their institutional policies may contribute to invalidation. Healthcare organizations could promote nonbinary visibility within their practice settings by utilizing gender-inclusive medical intake forms and paperwork, instructing providers/healthcare staff to routinely ask for patients’ affirmed names, gender, and pronouns, and implementing gender-neutral restrooms. In addition, education about invalidation and its effect on people’s wellbeing could be incorporated into school systems and public communication campaigns. Critically, clinicians and institutions can engage in advocacy work that targets policies and practices that promote invalidation on a structural level, including anti-trans legislation and policies limiting gender-affirming health care” (p. 421).

“This study had several limitations. First, the analysis was crosssectional, and we therefore cannot assess directionality or causality between invalidation and mental health outcomes. In addition, using mediation analysis with cross-sectional data to examine longitudinal behavioral processes may be prone to biases in estimation of effect size. Future longitudinal research should be conducted to explore the influence of invalidation on mental health pathways of TNB populations, as well as assess how invalidation experiences affect individuals across the life course. It should also be noted that invalidation experiences may occur more frequently during specific periods of time associated with key experiences or changes in a person’s life, as well as during periods of significant social change, which may not be adequately captured through cross-sectional data. In addition, the data for this study were collected between 2018 and 2019, and we have subsequently seen significant social, political, and cultural shifts that likely affected the frequency, types, and impact of invalidation experiences for TNB individuals. A life course approach could allow for a deeper exploration of invalidation experiences that unfold in TNB peoples’ lives over time, and within different social and historical contexts. 

Second, while we found that the Invalidation scale demonstrated sound psychometric properties, this was the first study to empirically test this novel instrument; more research is needed with larger and more diverse samples to provide further evidence of validity and utility of this measure. Importantly, while all our participants identified as part of the larger trans community, a recent population-based study found that the majority of nonbinary individuals do not identify as trans. Future research should be conducted with both trans and cisgender-identified nonbinary individuals, in order to explore differences of invalidation between these groups. Furthermore, it is also important to note that the distinction between nonbinary-trans and binary-trans is in itself a false binary. Previous research has documented that sizable percentages of trans men and trans women also simultaneously identify as nonbinary, in addition to using other gender identity labels. While we first asked our study participants to describe their gender identity through an open-ended question, the closed-ended question in the survey required participants to select the one gender identity category that best describes their identity. We likely underestimated the sample of nonbinary participants by not counting those who would have selected both binary and nonbinary categories if they had been given the option to do so. Future research should examine invalidation experiences using more expansive gender identity options. 

Third, during the scale creation process, we only observed metric invariance when we assessed for measurement invariance between the binary and nonbinary groups; we did not find evidence for scalar invariance. As past work has argued that this type of partial invariance is sufficient to make meaningful comparisons across groups we decided to include this comparison in our study. However, future research using the invalidation scale should further explore its characteristics among heterogeneous populations. 

Fourth, this paper is based on data from participants who had a mean age of 36.94, and few study participants were under the age of 21. Future studies should be conducted with samples that include larger numbers of both adolescents and young adults to explore whether and how age affects the manifestation of invalidation. Given that identity formation is a central developmental task during adolescence (Erikson, 1968), it is likely that invalidation experiences might be more stressful for adolescents than they are for older individuals. Furthermore, population research among TNB individuals suggests that nonbinary individuals tend to be younger in age. For example, a recent population-based survey of LGBTQ+ individuals in the United States found that the majority of nonbinary adults are under the age of 29. Similarly, a 2022 survey of LGBTQYouth (N=33,993) in the United States found that 37%of total participants ages 14–24 identified as nonbinary. These data suggest that a deeper exploration of the mental health implications of invalidation experienced during adolescence and emerging adulthood is warranted. 

Fifth, we did not examine how the effects of invalidation might potentially be moderated by psychosocial resources and other protective factors. Previous research has found that family acceptance, transgender pride, and social support from other trans people can moderate the effects of distal minority stressors (such as enacted stigma and gender-based discrimination) on mental health outcomes among TNB populations. Future research should examine the relationship between such protective factors and invalidation and the subsequent effects on mental health outcomes among nonbinary populations. 

Finally, while we did not find race/ethnicity to be a significant predictor of invalidation, we did not test for the interaction between race/ethnicity, gender identity, and invalidation, and the effects of those interactions on mental health outcomes, as this was beyond the scope of this study. Previous research has shown that TNB individuals of color face unique challenges at the intersection of their gender identity and race, which may have significant consequences for their mental health. Future research should explore how other axes of oppression (e.g., racism and heteronormativity) affect invalidation experiences of TNB individuals with multiple marginalized identities and their mental health outcomes” (p. 146).