How can using incorrect gender pronouns contribute to psychiatric disorders such as depression and anxiety?

Gender Pronouns and Mental Health in Transgender and Nonbinary Individuals

Using incorrect gender pronouns (misgendering) directly contributes to depression, anxiety, and suicidality in transgender and nonbinary (TNB) people through minority stress pathways, and clinicians must prioritize correct pronoun use as a fundamental component of mental health care.

The Direct Mental Health Impact of Misgendering

Misgendering is a pervasive stressor for TNB individuals that operates through the gender minority stress framework, where external discrimination and non-affirmation lead to internalized distress and adverse mental health outcomes 1.

Key evidence demonstrates:

• Daily misgendering affects 59% of nonbinary people, with 58% reporting being very or quite upset when misgendered, and only 13% feeling able to correct others most of the time 2
• Less frequent misgendering (weekly/monthly versus daily) is associated with significantly lower anxiety scores (β = -0.555,95% CI = -1.062, -0.048) in multivariable analyses 2
• Non-affirmation (which includes misgendering) improved significantly in affirmative therapy interventions, with large effect sizes (d = 1.07 pre-post, d = 1.00 pre-follow-up) when specifically addressed 1

The Mechanism: Minority Stress and Psychological Mediation

The relationship between misgendering and psychiatric disorders operates through established pathways 1:

• External minority stressors (discrimination, rejection, misgendering) lead to proximal stressors (internalized transphobia, expectations of rejection, identity concealment) 1
• These stressors are mediated by cognitive, interpersonal, and emotional psychological processes that increase vulnerability to depression, anxiety, PTSD, substance use, and suicidality 1
• The distress is not a cognitive distortion—expectations of rejection accurately predict future experiences of discrimination in this population 1

Clinical Outcomes: Depression, Anxiety, and Suicidality

The evidence linking pronoun misuse to specific psychiatric outcomes is robust:

Depression:

• TNB individuals face disproportionately high rates of depression, with 56.7% showing moderate to severe depression at baseline in clinical samples 3
• Affirmative interventions that address non-affirmation (including correct pronoun use) show 60% lower odds of depression (aOR 0.40,95% CI 0.17-0.95) 3
• Depression improved significantly in affirmative therapy addressing minority stress including misgendering (d = 0.60, p = .005) 1

Anxiety:

• 50% of TNB youth present with moderate to severe anxiety at baseline 3
• Daily misgendering is directly associated with higher anxiety scores in nonbinary individuals 2
• Shame related to non-affirmation decreased significantly with affirmative interventions (F(1,606) = 27.78, d = 0.43, p = .001) 1

Suicidality:

• 73% lower odds of suicidality (aOR 0.27,95% CI 0.11-0.65) among youth receiving gender-affirming care that includes proper pronoun use 3
• 43.3% of TNB youth report self-harm or suicidal thoughts at baseline 3
• Gender identity conversion efforts (which include refusing to use correct pronouns) combined with any history of suicide attempts creates the highest risk profile across all mental health outcomes 4

Essential Clinical Practice Guidelines

Immediate implementation steps 1:

1. State your own pronouns first ("I use ___ pronouns, what pronouns do you use?") to normalize the practice and create safety 1
2. Mirror the patient's language about their identities, relationships, pronouns, and bodies exactly as they present it 1
3. If you make an error, briefly apologize and move on—do not make the patient manage your discomfort 1
4. Document pronouns prominently in the medical record and ensure all staff use them consistently 1
5. Take a curious stance with open-ended questions rather than making assumptions about terminology 1

Critical Context: Gender Identity Is Not a Psychiatric Disorder

A fundamental distinction must be understood 1, 5:

• Gender identity expression itself is not a mental health condition and gender variations are not psychiatric disorders 1, 5
• Gender dysphoria refers to the psychological distress from incongruence between gender identity and sex assigned at birth, or from lack of affirmation by others 1
• The distress is iatrogenic when caused by misgendering—it results from external non-affirmation, not from the gender identity itself 1

Vulnerable Populations at Highest Risk

Certain groups experience more frequent misgendering and worse outcomes 2:

• Youth under 25 years (64% misgendered daily, p < .0001) 2
• Visibly disabled nonbinary individuals (74% misgendered daily, p = .003) 2
• Those assigned female at birth (61% misgendered daily, p < .0001) 2
• Racialized people of color assigned male at birth (65% misgendered daily, p < .0001) 2

The Protective Effect of Affirmation

Affirmative care that includes correct pronoun use demonstrates measurable benefits 1, 3:

• Improvements in pride (F(1,607) = 29.01, d = 0.43, p = .001) and positive affect (t(625) = -2.14, p = .03) 1
• Enhanced identity affirmation (t(16) = 2.98, d = 0.73, p = .009) and authenticity (t(17) = 2.52, d = 0.59, p = .02) 1
• Increased community connectedness (t(17) = 4.83, d = 1.14, p < .001) 1
• Better coping skills: active coping (d = 0.54, p = .012), emotional support (d = 0.51, p = .017), planning (d = 0.49, p = .024) 1

Common Pitfalls to Avoid

Never delay mental health treatment or gender-affirming care due to psychiatric symptoms—this worsens both gender dysphoria and mental health outcomes 6, 3. The evidence shows that affirmative care, including consistent pronoun use, improves psychiatric symptoms rather than requiring their resolution first 1, 3.

Never minimize the impact of "just" pronouns—the data clearly demonstrate that daily misgendering versus less frequent misgendering has measurable effects on anxiety and overall distress 2.

Never assume that TNB individuals with mental health conditions are more likely to perceive discrimination—the minority stress they report accurately reflects their lived experiences of prejudice 1.