The Relationship between Rejection Sensitivity and Suicide Risk in People with gender dysphoria: The Mediating Role of Depression

At birth, individuals manifest one of the gender identities, male or female, based on their biological anatomical status (Benjamin et al., 2023). However, there are instances where one's gender identity may not align with the gender assigned at birth (Abeyratne et al., 2022).  People with gender dysphoria are clinically described as an incongruence between the experienced gender and the assigned gender (Diaz, 2022). People with gender dysphoria encounter numerous challenges across various facets of life, including family, employment, and education (Bouman et al., 2017; Bosse et al., 2024). This is attributable to the significant disparity between the experienced and the assigned gender, leading to a strong inclination towards gender-role conformity, such as mimicking the dressing style and behaviors of the opposite gender, insistence on belonging to the opposite gender, preference for participating in activities and socializing with individuals of the opposite gender, aversion towards one's genitalia, and a strong desire for gender transition (Fernandes et al., 2023). These individuals struggle to fulfill their gender roles in society and within their families. It is not surprising that people with gender dysphoria exhibit poorer mental health compared to the general population and often opt to endure numerous difficulties rather than continue living, thus exhibiting a markedly high suicide risk (Falck & Bränström, 2023).

Studies indicate that 82% of People with gender dysphoria have contemplated suicide, with 40% having attempted suicide, with the highest rates observed among people with gender dysphoria youth (Rabasco & Andover, 2021). Also, based on Guzman-Parra et al. (2023), gender dysphoria groups, with and without gender reassignment, experience moderate levels of depression and suicidal ideation, but those without gender reassignment exhibit higher rates of suicidal ideation. Still, those without gender reassignment exhibit higher rates of suicidal ideation. Given Iran's cultural context, social acceptance of people with gender dysphoria behavior is exceedingly challenging and stressful (Pletta et al., 2024). People with gender dysphoria experience significant misunderstanding, non-acceptance, and rejection, factors that can exacerbate suicidal ideation and suicide risk (Rimmer et al., 2023).

Due to the social environment, cultural context, and familial dynamics, people with gender dysphoria are often subjected to a form of identity labeling known as gender dualism. This marginalizes individuals from complete social acceptance by others, exposing them to ostracism and social non-acceptance (Yasser et al., 2021). Discrimination, injustice, and victimization, including physical, verbal, and sexual abuse, are prevalent among people with gender dysphoria. People with gender dysphoria are particularly sensitive to social rejection and envy for greater understanding from others (Olsavsky et al., 2023). Social rejection is a pervasive and problematic issue that adversely affects people with gender dysphoria and their gender incongruence (Wang et al., 2020). Research indicated that being rejected by individuals and organizations can lead to detrimental outcomes such as low self-esteem, homelessness, engagement in sex work, and increased mental distress (Kcomt et al., 2020).

Some research indicated that experiences of rejection can lead to feelings of loneliness, hopelessness, and depression among gender-nonconforming individuals and exacerbate their mental health issues (Harper et al., 2020). In such circumstances where the people with gender dysphoria population are susceptible to various psychiatric disorders, research related to mental health in this group can be instrumental (James et al., 2020). Given that suicide risk is notably high within this group, the question arises as to why some people with gender dysphoria, despite facing significant societal rejection and enduring numerous social adversities, maintain relatively good mental health and consequently exhibit lower suicide risk than their peers (Yadegarfard et al., 2014). Lack of understanding is one of the elements of the feeling of rejection. It refers to a situation where an individual or a group fail to comprehend concepts, emotions, or specific aspects of a topic or situation accurately. This issue can stem from various factors, including insufficient knowledge, lack of experience, or cultural and linguistic differences (Harper et al., 2020). Hence, it seems pertinent to investigate other factors that may act as protective or exacerbating agents in the relationship between experiences of rejection and suicide risk among people with gender dysphoria (Wells et al., 2020).

As mentioned, increased feelings of rejection and social non-acceptance amplify interpersonal and social stress, consequently exacerbating symptoms of depression (Pellicane & Ciesla, 2022). In this regard, Pitts et al. (2009) indicated that individuals with gender dysphoria experience higher levels of depression compared to the general population. Pariseau (2019) demonstrated that feelings of rejection from family members are associated with increased levels of depression and a greater likelihood of reporting suicidal outcomes. Depression is one of the most prevalent psychiatric disorders, recognized as a disabling illness and a primary concern for global public health (Mohammadyfar et al., 2018). Studies also indicate that people with gender dysphoria have a higher risk of developing psychiatric disorders, particularly depression (Lampis et al., 2023). In this group, the likelihood of diagnosing depression is almost five times higher than in the general population (Russell et al., 2018). According to conducted studies, people with gender dysphoria or individuals with depression have a lower quality of life, struggle to engage in regular activities, and are more prone to physical health problems such as cardiovascular diseases, respiratory diseases, and metabolic syndrome (Green et al., 2022). Conversely, according to interpersonal models, social-interpersonal stressors significantly contribute to the onset and maintenance of depression. Research has shown a correlation between depression and increased suicide risk in people with gender dysphoria (Bockting et al., 2013).  Symptoms of depression, such as feelings of worthlessness, hopelessness, and low self-esteem, can be a factor in the perception of rejection (Eynaki et al., 2021). Depression can act as a mediator between rejection sensitivity and suicidal ideation by fueling feelings of failure and the hopelessness stemming from rejection (Lampis et al., 2023).

In Iran, many of such individuals do not have suitable and stable jobs, and are not, accordingly, accepted in high-ranking positions. Even if they find a job, when the employer becomes aware of their conditions, they either get fired or are subjected to exploitation and unethical proposals. Therefore, due to a lack of support from government institutions, they feel insecure and are driven into isolation and loneliness. The lack of information and awareness from the national media leads to families remaining unaware of these individuals. However, by raising awareness in society, the taboo surrounding this issue would be broken, and people with gender dysphoria would disclose their condition (Hakeem, 2008). Rejection and neglect are issues that people with gender dysphoria grapple with at various levels of their social lives. The feeling of rejection can lead to their exclusion from many social activities and participation in the community, gradually weakening their relationships with others (Dickens, 2020). The high prevalence of severe depression symptoms, coupled with violence and psychological and sexual discrimination, creates cycles of vulnerability and has significant public health implications (Daniel Sout, 2023).

Despite growing awareness of gender identities, in-depth and comprehensive research on the specific experiences of people with gender dysphoria individuals remains scarce. Thus, it appears essential to assess the relationship between rejection sensitivity and psychological distress that may result from this sensitivity.  People with gender dysphoria individuals face numerous challenges such as social non-acceptance, injustice, and feelings of victimization, which increase their suicide risk, particularly in traditional societies like Iran. Through research conducted in domestic and international sources, a significant research gap is evident in this field. The present study aims to investigate the relationship between rejection sensitivity and suicide risk, with the mediating role of depression, among people with gender dysphoria. Research on people with gender dysphoria requires more attention and advancement. As society is rapidly changing, a deeper understanding of the experiences of these individuals will contribute to creating a more just and inclusive society.

Method

The present study was descriptive and correlational. The statistical population of the research included transsexual people from Iranian gender dysphoria, during 2022-2023. The sample size in Structural Equation Modeling (SEM) should be at least 200 individuals (Kline, 2010). By using purposive and snowball sampling methods, 266 questionnaires were distributed based on the inclusion criteria for individuals seeking support from the people with gender dysphoria Support Association in Tehran. In this study, there was no restricted questionnaire.

The researcher, after identifying these individuals, examined the criteria for inclusion and exclusion through an interview. Inclusion criteria were having a diagnostic criterion for people with gender dysphoria by a psychiatrist or psychologist, legal physician confirmation, and at least a ninth-grade education to ensure comprehension and completion of questionnaire items. Exclusion criteria included exhibiting acute psychiatric symptoms (such as bipolar disorder and schizophrenia diagnosed by a psychiatrist or psychologist and their confirmation) and the use of psychiatric medications (non-use of the medications risperidone, clozapine, olanzapine, ziprasidone, aripiprazole, and lithium). All participating samples had a letter from a psychiatrist indicating the absence of the mentioned disorders, which was verified in the initial interview by the researchers.

 To begin, after obtaining ethical approval, the researchers, through participation in events and seminars organized by people with gender dysphoria, support the association and meticulous review of profiles to ensure compliance with research criteria, identified several individuals with gender dysphoria. Subsequently, contact was made with them, expressing gratitude for their cooperation, and they were asked to receive and respond to the questionnaire link via the WhatsApp application. It is noteworthy that the researchers also established communication with several counseling, psychological, and psychiatric centers in Tehran for the treatment of sexual disorders. Through therapists in these centers, people with gender dysphoria were identified, and links were sent to them accordingly. The researcher contacted the Psychiatry Institute and communicated with several people with gender dysphoria, following the same procedure as before, ensuring compliance with entry criteria. It is essential to emphasize that, to uphold ethical considerations, the research objectives were clearly explained at all stages to the target sample group, while also reminding them of the optional nature of providing personal information. Complete assurance of confidentiality was provided to them. Finally, after approximately one year (January 2023 to December 2023), the sample size (266 completed questionnaires) was determined.

The research sample consisted of people with gender dysphoria, with 132 (49.6 percent) assigned female at birth & 134 (50.4 percent) assigned male at birth based on physiological gender, while 132 (49.6 percent) identified as female to male & 134 (50.4 percent) as male to female based on gender identity. Regarding marital status, the majority of respondents, namely 247 individuals (92.9 percent), were single, while 15 individuals (5.6 percent) were married, & four individuals (1.5 percent) were divorced. In terms of education, 15 individuals (7.5 percent) had education levels below a high school diploma, 141 individuals (53 percent) had a high school diploma, & 110 individuals (41.3 percent) had university education. The average age of respondents was 23.52 years with a standard deviation of 37.5 years, and an age range of 15-46. 

Measures

Suicidal Thoughts Scale (STS): The Suicidal Ideation Scale was developed by Beck (1979) to assess an individual's propensity for suicide. This Scale provides a numerical estimate of the severity of suicidal thoughts and tendencies. This scale comprises 19 items graded on a four-point scale from 0 (least severe) to 2 (most severe). This scale is scored on a four-point scale. Each question is scored separately, aiming to increase the likelihood of identifying suicide risk. Beck (1979) reported that Cronbach's alpha for the total score on this scale is 0.93. For subscales including hopelessness, suicidal thoughts, hostility, and negative self-evaluation subscales, it ranges from 0.62 to 0.89, indicating that the scale effectively distinguishes between suicidal and non-suicidal individuals (Krug et al., 2002). Scores between 75-100, 50-74, and between 25-49 indicate high, moderate, and low suicide risk, respectively. The scale's reliability, assessed via Cronbach's alpha, is 0.95, and using the split-half method is 0.75. Sueki (2022) reported (Cronbach's alpha for this scale is reported as 0.89, and its test-retest reliability is 0.69. In an Iranian study involving adolescents, this scale was used, demonstrating a correlation between test scores and symptoms of depression and anxiety, indicating its ability to differentiate adolescents prone to suicide (Ziaei et al., 2017). In Iran, the reliability of the scale was reported as 0.89 using Cronbach's alpha. In this study, Cronbach's alpha was found to be 0.93 (Anisi et al., 2005).

Rejection Sensitivity Questionnaire (RSQ): This questionnaire was designed by Downey and Feldman )1996) and consists of 18 two-part questions (A and B) that are evaluated based on a 6-point Likert scale. The first part of each question assesses the level of anxiety experienced by the individual in the given situation, while the second part evaluates the likelihood of receiving a positive response from the other person. Part "A" is scored from 1 (not at all anxious) to 6 (very anxious), and Part "B" is scored from 1 (very unlikely) to 6 (very likely). Downey and Feldman (1996) reported the sensitivity to rejection by first subtracting the scores for "expectancy of acceptance" in each situation (part B) from 7 to compute the "expectancy of rejection" scores. Then, they multiplied the expectancy of rejection score in each situation by the "anxiety level" and calculated the average scores across the 18 situations. Higher scores on this questionnaire indicate higher sensitivity to rejection and a more negative attitude toward rejection. They reported internal consistency reliability of the rejection sensitivity scale using Cronbach's alpha as 0.89 and 0.91 for test-retest reliability. In the study by Ayduk et al. (2008), Cronbach's alpha for the reliability of the questionnaire was 0.83, and on Iranian students, the reliability was 0.84 (Khoshkam et al., 2012). In this study, Cronbach's alpha was calculated as 0.90.

Beck Depression Inventory (BDI): This scale was designed by Beck et al. (1961) to assess feelings of guilt, failure, inadequacy, sleep disturbance, and agitation, and consists of 21 questions scored on a 4-point Likert scale from 0 to 3 (Beck et al., 1997). Scores range from a minimum of 0 to a maximum of 63. Scores of 0 to 13 indicate mild depression, scores of 14 to 19 indicate moderate depression, and scores of 29 to 63 indicate severe depression (Beck et al., 1996). In the study by Beck et al. (1996), the average alpha coefficient for internal consistency was 0.86 for psychiatric patients and 0.81 for non-psychiatric patients. The Persian version of the inventory had a reliability coefficient of 0.92 for a sample of depressed patients and 0.93 for a sample of students (Dehestani et al., 2018). The Cronbach's alpha in this study was also determined to be 0.92.

Data Analysis

Descriptive statistics, including mean and standard deviation, were used, along with inferential statistics, to address the research questions. The relationship between variables was examined using Pearson correlation analysis, and the research model was tested using Structural Equation Modeling (SEM) techniques. Data analysis was conducted using the statistical software packages SPSS 28 and AMOS 24.

Results

Data screening was conducted, and univariate outliers were identified and corrected using box plots for single-variable outliers and Mahalanobis distance for multivariate outliers. The assumption of multicollinearity with the inflation factor was assessed against the inflation factor, with the obtained statistic for feelings of rejection and depression being 1.44. This value was found to be less than the criterion of 5, indicating no multicollinearity. The assumption of multivariate normality was examined by assessing skewness and kurtosis values, which were reported in the AMOS software output. Since the critical ratio obtained was 2.29, within range of -2 to +2, assumption of multivariate normality was confirmed. In Table 1, descriptive statistics for variables and Pearson correlation coefficients are provided.

Table 1. Correlation between variables along with descriptive statistics

The conceptual model of the research was tested using Structural Equation Modeling (SEM) technique in the AMOS software. Figure 1 showed the proposed model in standardized coefficient form, with significance levels denoted by asterisks.

Figure 1. The relation between feeling rejected and risk of suicide: with the mediation role of depression (**)

Figure 1 showed that the relationship of feelings of rejection on depression and relationship of depression on suicidal risk was confirmed (p < 0.01). The strongest effect on suicidal risk was attributed to depression, with a coefficient of 0.72. Model fit indices are provided in Table 2.

Table 2. Model fit indices

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The coefficient of determination (R²) for the criterion variable, suicidal risk, was 0.45. Accordingly, the variables of feelings of rejection and depression could explain 45 percent of the variance in suicidal risk. The mediation role of depression in the relationship between feelings of rejection and suicidal risk was analyzed using the bootstrapping method and the standard error of this method in the AMOS software, with the findings presented in Table 2.

By evaluating all the fit indices in Table 2, it can be inferred that in the experimental model, all fit indices have appropriate and acceptable values. None of the fit indices have weak values, and all indices fall within an acceptable range, indicating that the overall model was confirmed and the data had a suitable alignment with the conceptual model. The coefficient of determination for the dependent variable of suicide risk was 0.45, which is an acceptable value as it is greater than the average value of 0.33, indicating a reasonable explanatory power of the model. Accordingly, the variables of feelings of rejection and depression were able to explain 45% of the variance in suicide risk. Table 2 presents the results of direct relationships based on the structural equation modeling method. Table 2 shows the results of examining direct effects based on the results of structural equation modeling tests.

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The findings indicated that the mediating role of depression in the relationship between feelings of rejection and suicidal risk was confirmed (p < 0.001). The indirect relationship intensity was 0.414, indicating a strong indirect relationship intensity; the mediating role of depression was confirmed.

According to the results, rejection sensation did not have a direct effect on suicide risk. However, the findings confirmed the effect of rejection sensation on the mediating variable of depression, with a positive direction and a strong effect size of 0.581 (p < 0.001). Additionally, the effect of the mediating variable of depression on suicide risk was confirmed, with a positive direction and a significant effect size of 0.715 (p < 0.05). The mediating role of depression in the relationship between rejection sensation and suicide risk was analyzed using the bootstrapping method and the standard error obtained from this method in the Amos Software. The mediation test results showed that the mediating role of depression in the relationship between rejection sensation and suicide risk was confirmed (β = 0.415, SE = 0.060, t = 6.92, p < 0.001). The strength of the indirect effect was 0.415, indicating a strong indirect effect.  The total effect (sum of direct and indirect effects) of rejection on suicide risk was 0.504. The findings showed that 82 percent of the total effects of rejection on suicide risk were indirect. Also, given that the direct effect of rejection on suicide risk was not significant, the mediation role of the depression variable can be considered complete. Overall, rejection did not have a direct effect on suicide risk, but it had a significant indirect effect (through the mediation of depression) on suicide risk.

Discussion

The present study aimed to investigate the relationship between feelings of rejection and suicidal risk in people with gender dysphoria, considering the complete mediating role of depression. According to the proposed model, the direct effect has been rejected, meaning that the variable of perceived rejection does not directly influence the risk of suicide, and all its causality is mediated through depression. The results of data analysis revealed a significant and positive relationship between feelings of rejection and depression with suicidal risk. A positive relationship with strong intensity was observed between feelings of rejection and depression. Feelings of rejection and depression could explain 45% of the variance in suicidal risk. The complete mediating role of depression in the relationship between feelings of rejection and suicidal risk in people with gender dysphoria was confirmed.

These findings align with previous research (Bockting et al., 2016) indicating a significant and meaningful (positive) relationship between feelings of rejection and depression in people with gender dysphoria. This finding suggests that people with gender dysphoria, as a heterogeneous gender minority group, face distinct challenges due to societal expectations differing from their gender identity. They encounter labeling and societal scrutiny alongside personal struggles. Feelings understood by others, coupled with coping with life’s significant and stressful events, are particularly crucial for people with gender dysphoria, especially within the context of family, as self-acceptance and self-esteem begin early in life and are influenced by parental attitudes. Moreover, people with gender dysphoria often face significant pressure from parents and peers to conform to their physiological gender, contributing to stereotypes and, subsequently, an increased risk of depression symptoms, trauma, internalization of problems, and outward manifestation of symptoms (Olsavsky et al., 2023).

The finding that a significant and positive relationship exists between feelings of rejection and depression with suicidal risk is consistent with the results of previous studies (Boza & Nicholson Perry, 2014). In elucidating this finding, it can be stated that attitudes reflecting family bias, particularly, and societal bias generally, towards gender differences, adversely influence the well-being of youths, diminish their self-esteem, isolate them, and exacerbate or induce depression symptoms. At times, individuals may attempt to conceal their gender differences out of fear of safety concerns, further exacerbating their psychological distress. However, some people with gender dysphoria conceal their circumstances due to internal anguish and may not seek help.

Nevertheless, the fear of rejection, whether real or perceived, increases the risk of depression and, in many cases, individual pressures and social tensions become so intolerable that suicide appears to be the only recourse (Falak et al., 2020). Based on the aforementioned finding, it is suggested that symptoms of depression and suicidal ideation in people with gender dysphoria be regularly assessed in relevant clinics.

The finding that feelings of rejection indirectly influence suicidal ideation through depression is consistent with some studies (Bockting, 2016). In explaining this finding, it can be argued that social acceptance entails the availability of support and understanding of an individual's unique identity by others (Golbahari et al., 2022). Those who experience social rejection endure emotional and mental challenges due to a lack of acceptance (Farahmand & Danafar, 2017). Hence, external sources of support for coping with identity issues are limited, and possibly due to rejection or non-acceptance by others, their problems are exacerbated. It appears that the sense of social rejection increases the risk of depression, and not only can real rejection but also perceived rejection predict depression in people with gender dysphoria, consequently increasing the likelihood of suicidal ideation (Hoffman, 2014). It is imperative for relevant therapists to prioritize family counseling.

 The finding that feelings of rejection and depression are in line with the variance in suicidal risk is consistent with the findings of studies (Wang et al., 2020). In explaining this, it can be said that people with gender dysphoria navigate through numerous challenges due to their unique life circumstances and gender identity (Farahmand & Danafar, 2017). From societal stigma and ridicule to family rejection and the inability to undergo medical procedures and gender-affirming surgeries, these experiences may profoundly influence an individual's psyche and behavior, playing a significant role in shaping their personality and decisions (Hoffman, 2014).

Inappropriate treatment not only fails to prevent problems but also prompts these individuals to withdraw from their family environment, leading to loneliness and isolation, which may drive them towards suicidal ideation (Ghosh et al., 2022). Unfortunately, experiences of rejection have left them disillusioned with life. Concerns about societal confrontations, ridicule, and insults faced by people with gender dysphoria in public spaces have greatly amplified their psychological distress, plunging them into deep depression and steering them towards suicidal thoughts. The existence of suicidal ideation ultimately culminates in suicide attempts. The crucial point here is that suicidal thoughts do not arise in isolation; rather, existing discrimination, family rejection, expulsion from school or workplace, and financial difficulties all play a role in the genesis of these thoughts. Research underscores the need for the development of specialized clinical and social approaches for people with gender dysphoria and their families. Establishing family-centered and collaborative programs and policies to empower these individuals to avoid the emotional and psychological costs associated with rejection and non-acceptance is of paramount importance (Banerjee et al., 2020; Lampis et al., 2023). Raising awareness about these issues can contribute to improving the conditions of people with gender dysphoria in society.

Conclusion

The presence of people with gender dysphoria in society and their acceptance by the public is a significant concern, as social rejection inflicts severe psychological damage and leads to their isolation and marginalization. This stems from feelings of injustice, victimization, and lack of understanding, resulting in depression and unexpected suicidal ideation. Utilizing these findings in therapeutic, psycho-educational interventions and policy-making is of paramount importance.

Howeverthis research has faced limitations. Among the limitations of this study are the study population and the type of research, which is based on correlational methods. This should be considered in elucidating the causality of variables. In this study, some intervening variables, such as family, cultural, social, economic factors, and personality traits, were not examined, reducing the generalizability of the study findings. Cross-sectional research is another limitation since conducting longitudinal studies in these areas could provide a more accurate explanation of variable mechanisms.

Given the results of this study, since feelings of rejection in people with gender dysphoria individuals are crucial in predicting depression and increasing the risk of suicide, it is suggested that future studies also consider other variables related to feelings of rejection and its fundamental role in increasing psychological damage and suicide risk in people with gender dysphoria individuals. Sources of feelings of rejection such as social experiences, unrealistic expectations, communication problems, and culture and society. In this regard, it is better to use longitudinal studies and study demographic variables, as well as to increase social acceptance and better understanding of the people in gender dysphoria community. It is recommended to take necessary actions, such as utilizing mass media, organizing scientific sessions, and holding psycho-educational sessions for families, to increase awareness among individuals and families.

Acknowledgments

The authors would like to express their gratitude to all the participants.

Conflict of Interests

None.

Ethical Consideration

This article is derived from a doctoral thesis at the Islamic Azad University, Roudehen Branch. It also has an ethics code IR.IAU.R.REC.1402.031 from the Ethics Committee of the Islamic Azad University, Roudehen Branch.

Authors’ Contribution

The authors declare that there is no conflict of interest in this article.

Fereshteh Modir Fallah: Study design, data collection, data analysis and interpretation, drafting the initial manuscript. 

- Mandana Niknam: Conceptualization and study design, supervision of the research process, critical revision of intellectual content, statistical analysis. 

- Simin Dokht Rezakhani: Contribution to study design, critical revision of intellectual content, provision of methodological guidance. 

- Simin Hosseinian: Provided consultation in the initial stages of study design, contribution to manuscript revision.

Funding

The present study was accomplished without any outside financial support.

Patient Consent                                                 

Before inclusion, all participants signed informed consent forms.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.