This study assessed the quality of life, depression, anxiety, stress, and contributing factors in transgender women.
Considering the quality of life, our results showed that 48% of transgender people reported OQOL as moderate. This finding could be interpreted with a significant positive relationship between education and economic status with subscales of quality of life. Considering that the majority of people in the present study did not have appropriate education, economic status, and profession, it seems that these factors could have an inverse effect on physical health, psychological health, environment, and ultimately, OQOL. Other studies have shown that there is a significant relationship between the QOL of transgender women and their education, profession, income, and psychological stability [18], income and QOL [19], and income and education with QOL [2, 20]. It seems that higher education is perceived as an enabling factor for women, leading to an appropriate profession and higher income and improved QOL.
Considering the QOL dimensions, the highest mean belonged to physical health (53.9%). The higher score in physical health could be explained by the age average of 27 of the subjects and the fact that the majority of them (74%) had not undergone gender reassignment surgery. In other studies, the highest QOL belonged to the transgender people’s physical function [21], who sometimes had a higher score than the general population [22, 23]. However, the highest QOL in transgender people was reported in the environment in two studies [2, 24], which could be attributed to the higher employment and income of the transgender people in that study compared to ours. In the present study, the lowest quality of life belonged to social relationships (39.2), which needs attention. The majority of the transgender people in this study (63%) had low family support. It seems that the lack of family support and social stigma could lead to social deprivation and the limited relationship of these people with others. Low social relationship scores are observed in the two other studies (2, 24). The QOL of the participants in the social relationship dimension in this study decreased with age, which is not far from expectation considering the higher connection of younger transgender people with social media.
The results of Table 3 showed that the OQOL of transgender people has a significant relationship with their depression, anxiety, and stress, which is consistent with Gorin’s study [25]. Of course, paying attention to the mental health of transgender people could significantly improve their QOL.
Considering mental health, although the mean score of depression in the transgender women shows mild depression, 22% had severe and extremely severe depression, which deserves attention. Considering the considerable effects of economic status in alleviating depression (37%), it is very important to pay attention to the living and financial needs of these people, which is consistent with other studies. [26, 27].
Considering anxiety, although the mean score of anxiety was mild in transgender women, 20% had severe and extremely severe anxiety. Moreover, improved education was associated with decreased anxiety in them. Improved education will lead to better social status for transgender people and decrease their worries by creating self-confidence. The results of other studies show the positive effects of education on mental health [28, 29].
In the stress dimension, although the mean score of stress was normal in transgender women, 17.3% of them had severe and extremely severe stress. Although education is a contributing factor to stress, sexual violence was associated with a considerable increase in stress scores (49%). The high rate of sexual violence in this study (63%) and its relationship with stress show that these people are exceptionally mentally vulnerable and should be well attended to counseling, support groups, and health promotion programs. The results of two other studies also confirm the association between sexual violence and mental health disorders in transgender people [30, 31].
Contrary to our expectation, this study showed that those who had lower family support had lower stress compared with those with higher family support. However, it should be regarded that this finding in our study should be cautiously interpreted due to the level of significance (p < 0.05), the very small number of people with high family support (9.4%), and the fact that the results of other studies that are contrary to the present study [32–35]. The only interpretation that may partially explain this issue may be that the high support of a family can lead to incompatibility and stress in individuals when there are many problems for transgender people in society.
One of the limitations of this study is the lack of a control group from the general population to compare the outcomes with those of transgender people. Nevertheless, the present study is of the first studies in Iran that have assessed the quality of life, depression, anxiety, stress, the contributing factors, and the relationship of these factors which each other and with the demographic variables, in such considerable size.