Gender Minority Stress, Depression, and Anxiety in a Transgender High School Student

“Jamie” looks like a typical high school sophomore boy. He is clean-cut and dressed in baggy pants, a T-shirt, and a stocking cap. Jamie was born in a girl’s body. He came out to his family as transgender when he was 14 years old. Jamie’s mother was very supportive from the start. She bought Jamie a binder to reduce the appearance of his developing breasts, and took him shopping for masculine clothing. She also sought therapy for Jamie with a provider who specialized in gender identity issues and encouraged the rest of the family to attend their own therapy to help them adjust. Jamie’s father struggled a bit more with the news. He did not say anything overtly negative, but Jamie noticed that he had become more distant, no longer spending time watching hockey games together. Jamie struggled with school avoidance, as well as self-harm by cutting and burning, and he self-medicated with marijuana. He said that he was doing everything he could to numb the difficult feelings he was experiencing. He was diagnosed with major depressive disorder by his primary care physician and after a trial of fluoxetine did not help, he was switched to escitalopram.

Within weeks of coming out to his family, Jamie felt so hopeless and overwhelmed with his desire to fully transition and be accepted by his peers and family that he took an overdose of escitalopram in a suicide attempt. Soon after taking the overdose, he disclosed it to his mother, who took him to the hospital. During his admission, he learned coping skills and decided to quit his self-harm and his marijuana use. His motivation to improve was that it would allow him to start testosterone therapy for his medical transition. He was discharged after 1 week on a medication regimen of duloxetine (for depressive symptoms), propranolol (for school anxiety), and risperidone (for mood instability).

After Jamie’s hospital admission, he and his mother presented to the University of Colorado Imagine Clinic (a specialty clinic for individuals of all ages who identify as LGBT—lesbian, gay, bisexual, or transgender) for a medication evaluation for ongoing symptoms of depression and anxiety. Jamie had missed a significant number of school days even before his hospitalization, and returning to school was a major hurdle for him to overcome. When he tried to attend school, he became tachycardic and tachypneic, and he would frequently have to excuse himself to the nurse’s office or ask his mother to come get him to calm down. Jamie explained that he felt immensely uncomfortable at school. He would compare himself to his male peers and feel that he would never be able to measure up to their “maleness,” that he was a fraud, and that he did not fit in. He feared that even after he began medically transitioning, there would never be a point at which he could feel comfortable in his own body. Jamie did not wish to attend groups with transgender peers for support, as he wanted to be identified as male rather than as transgender. At intake, Jamie was diagnosed with gender dysphoria, generalized anxiety disorder, and major depressive disorder. No medication changes were made at that time, as his depression and urges to self-harm had improved and he was scheduled to start testosterone therapy in 2 months.

The school offered Jamie the flexibility to take a reduced school day and the option of retreating to the nurse’s office whenever he needed a break during the school day or if he needed to use the restroom. He was permitted to complete his physical education credits through an online course to avoid the locker room. Those measures were helpful initially, and Jamie’s depressive and anxious symptoms improved. Jamie’s family felt satisfied with the school’s support through this difficult transition. However, as Jamie began spending more time in school, he was bullied by peers. He had a physical altercation with a peer who disparaged his gender identity. Jamie and the other boy were both suspended. After his suspension, he avoided use of the restroom at school completely, and he no longer wanted to use his accommodations to go to the nurse’s office. He stated that he would make his peers feel uncomfortable or, even worse, that he would be ostracized or bullied for using either the boys’ or the girls’ restroom. Jamie’s anxiety over being ridiculed and, at times, his fear for his safety at school led to worsening school avoidance. His anxiety escalated to multiple daily episodes of hyperventilation, and he complained of constant fatigue.

Jamie’s difficulty attending classes led him to the brink of failing his courses. The school decided to transition him fully to online school for the remainder of the school year to recover the necessary credits. He continued in therapy and medication management, with the goal of supporting his transition back to school in the fall.