BATTLE of the (TRANS) ATLANTIC

for the lights we have lost in the dark

Hi! I'm Billie.

I investigate human rights abuses and make maps. I also happen to be transgender.

I am going to tell you the story of mental health and gender identity in America and Britain today. In this StoryMap, I combine maps, data, and discussion to bring the mental health crisis and (trans) moral panic to life. Yet I don't think that is enough. To help you truly understand and feel this perilous moment, I am sharing myself with you, too. You will follow my journey and you will experience my joy and pain. In so doing, I sincerely hope that it helps you relate to those living with mental health conditions, and to those with different gender identities. I thus hope that you will approach this story - my story - with gentleness, grace, and an open mind. I would never claim to represent my community, but I want you to know that this is more than just my story - for many of us, this is our story.

On both sides of the Atlantic, there is growing recognition of a mental health crisis that has taken root in both countries. In the US, 1 in 5 Americans are accessing mental health services - more than ever before - and some 50 million Americans have some form of mental health condition. More than half do not receive treatment - some 27 million people. As the mental health of society declines, the strain on the mental healthcare system increases. In the UK, the National Health Service (the UK's universal healthcare system) demand is vastly outstripping supply. 1.2 million Britons are waiting for support, whilst acute inpatient facilities do not have enough beds to meet demand. The vacancy rates for mental health staff are above 20%. In both countries, the statistics of youth mental health are horrifying. Make no mistake, a serious mental health crisis is here.

In both countries, the transgender community is exceptionally vulnerable to mental health concerns. As the rights and lives of trans people have been politicized and weaponized on both sides of the Atlantic, hatred both online and in person has grown exponentially. Unsurprisingly, the self-harm and suicide rates for both trans adults and youth are frightening.

This StoryMap explores the mental health crisis as a transatlantic phenomenon before engaging with the challenges faced by the transgender community in a traumatic time.

It may be fashionable to pretend that being transgender is the new fad, but transgender people have existed forever. From Ancient Egypt to Ancient Rome, from indigenous American two-spirits to the Hijra of India and the Māhū of Hawaii and Tahiti, transgender and third-gender people are omnipresent in both time and space, and we always have been. Today, the trans community is at the heart of a profound moral panic, inspired by the far-right, that threatens our rights, safety, and futures. I promise that we are not the bogeyman you might think we are - let me explain below.

In simplest terms, a transgender person is someone whose gender identity does not match the sex they were assigned at birth. Speaking broadly, there are typically three types of trans people. The first, transmen, are people assigned female at birth whose gender identity is of a male. The second, transwomen, are people assigned male at birth whose gender identity is that of a female. The third, non-binary people, are people assigned male or female at birth who do not identify with either gender.

To make this easier, I am a transwoman. That means I was born male, but my gender identity has always been that of a woman. I have known that I was trans since I was a little kid, and I can trace the origins of my (very long) journey online in a blog I wrote in 2011 when I was a distressed hot mess of a trans teenager. At 16, I used that blog to scream into a void that never answered back, and that certainly never gave me the gender care that I needed. Many trans people feel profound distress at the conflict and discord between their assigned sex and their gender identity. This is known as 'gender dysphoria', and it is something I suffer with extensively. To put it in perspective, my dysphoria is so debilitating that I can barely look in the mirror - when I do, it can trigger terrible waves of depression or even immediate suicidal ideation. Dysphoria is no small thing - it is all too real, and you wouldn't imagine how much it hurts.

Gender Dysphoria can be deadly due to its potentially severe effects on the mental health of trans people. In response to this serious problem, most medical systems offer 'gender-affirming care', which offers mental healthcare, medical care, and social services. For children, this might involve therapy, puberty blockers, and social transitioning. For adults, this can include mental health support, hormone therapy, and surgery. Whether an individual chooses to receive hormone therapy or surgery does not change their transness, and it is important to consider that many people across the world do not have access to this treatment. Social transitioning just means beginning to live as your 'true' gender - changing names, pronouns, and presenting as yourself in public. I had been out to friends for many years, but it took me a long time to pick up the courage to tell my family. I was so full of fear that it took me a long time to be Billie in public, too. I first began to receive gender-affirming care when I moved to Boston, and I have (a lot of) therapy and I am receiving hormone therapy (HRT) too. HRT has been life-changing because my body is finally starting to look like I have needed it to. I may only have fully 'came out' and socially transitioned earlier this year, but I have always - always - been transgender.

The map below shows just a few famous trans figures throughout history. Click on the red icons to learn a little more about them!

We live in a time where mental health is increasingly destigmatized. It is not unusual to hear a colleague state that they are 'taking a mental health day' or that they find solidarity and support in those who also receive therapy. Teletherapy adverts interrupt our television programs and YouTube videos, and celebrities discuss their mental health in interviews. Beneath this is an important shift in public perception that mental health is important, and that it is not weakness. It is a growing problem for the military, and particularly among the veterans community. Four times more US Veterans have died of suicide than have died in combat in Afghanistan and Iraq combined since 2001.

The WHO states that 'Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in. Mental health is a basic human right. And it is crucial to personal, community and socio-economic development'. A related concept, wellness, applies a holistic approach in identifying several factors that contribute to overall wellness, such as spirituality and sociality. An individual will then consider their strengths - perhaps they are good at maintaining physical fitness, or they have a good social circle- and then they will consider where they might make changes to improve their overall wellness.

NAMI states that '43.8 million adults experience mental illness in a given year. 1 in 5 adults in America experience a mental illness. Nearly 1 in 25 (10 million) adults in America live with a serious mental illness'. Some 45,900 Americans died of suicide in 2020. Mental Health is an international, national, and local public health issue with deadly consequences.

After the systematic killings of the mentally ill in Nazi Concentration Camps, the psychiatric hospital – then a prison-like, overcrowded, oppressive setting – came under scrutiny in both Europe and the United States. A vast number of psychiatric hospitals had been established throughout the world from the Victorian era to the start of the Second World War. In the 1950s, the ‘deinstitutionalization’ movement emerged, which aimed to prevent the (long-term) institutionalization of individuals into the mental healthcare system. Instead, an onus was placed on providing mental health care in communities themselves and substantially reducing the number of psychiatric beds (and thus hospitals) available over time. This shift from a hospital-based system to a community-based system has been noted in much of Europe and throughout the United States. To put the deinstitutionalization practice into perspective, the US had 340 psychiatric beds for every 100k people in 1955. In 2005, there were only 17 per 100k people – a colossal reduction. Similarly, there were more than 500,000 people living in psychiatric hospitals in the US during the 50s. By the 1980s, that number was around 100,000 – and the number will be even lower today.

The shift to community-based care has included the development and implementation of intensive outpatient programs and partial hospitalization, both of which provide elevated levels of care for acute patients without psychiatric hospital admission. During the pandemic, many of these programs offered remote options that may increase accessibility across a state, for example. Ideally, such programs are combined with psychotherapy and psychiatry support – including medication management. Yet the shift to community-based care relies on the presence of (and investment in) mental health services in local areas, and that is often not the case, creating care inequities. In more rural, sparsely populated states, accessing any mental health services can be challenging. The inherently unequal distribution and quality of community mental health services can exacerbate existing, intersectional inequalities. It is also important to consider the troubling relationship between mental health and the law-enforcement/carceral system – the police are usually the units to respond to mental health crises, but they are inadequately trained and equipped to do so. With some 10% of police calls being mental health-related, this leads to both police shootings and arrests. One commentator suggests that ‘Jails have become society’s primary mental institutions’.

Click on the icon at right hand side of the image to begin the slideshow.

In the United States, there is growing concern, if not panic, about a national mental health crisis. Some 90% of Americans believe a mental health crisis exists, and the Biden Administration has even acknowledged this when launching a new mental healthcare plan. In simple terms, Americans are increasingly feeling mentally unhealthy.

The map below highlights the change in mentally unhealthy days between 2013 and 2023, which is a 10-year interval. It utilizes county-level data from the County Health Rankings. Any grey counties are those that did not supply or record that data in the survey year.

Scrolling left to right reveals the change from 2013 to 2023. You can click on any county to reveal its data.

There is an extraordinary difference between 2013 and 2023 - it is clear that across the country, Americans are feeling worse. It is worth noting that many of the more acute areas in the 2013 data appear even more acute in the 2023 data.

In the United Kingdom, the National Health Service (NHS) is struggling to respond to what has been termed a 'national emergency'. Staffing levels have increased, but they have been far outpaced by the rapidly growing need for mental health support. Some 1.2 million people are awaiting mental health support. There is considerable concern over inadequate service provision to the young. Even for basic support receiving care can take up to 14 weeks - a disaster for those that need care urgently. Available beds for the acutely mentally ill have fallen by some 22% since 2010/2011. The lack of availability has led to many patients being taken to hospitals so far away that they are considered 'inappropriate' to receive care. It seems that the UK is only just beginning to understand both the scale of needed mental healthcare and the lack of treatment services available, unlike the United States.

Whilst it is difficult to measure differences in mental healthcare across the United States, the below maps isolate Mental Health Providers (per 100k) and then the Population of (Mental) Health Professional Shortage Areas. In short, they show how many mental health providers there are per state, and how many people live in areas with insufficient mental health staff per state. Whilst many of the states with the biggest populations with insufficient mental health staff match the mental health provider map, there are also interesting differences - like in the sparsely populated Northwest / Mountain West.

Yet the psychiatric hospital still plays an important role in the US mental health care system, providing treatment

The above map series identifies an important correlation of sorts. It seems evident that suicide rates are substantially higher in areas with limited or no access to psychiatric hospitals. This correlation is most visible in the Mountain West region.

The United Kingdom and the United States are grappling with the challenges of increasing mental health needs with inadequate mental health resources. In the US, this can vary deeply by both state and county, underlining how this is a complex issue requiring substantial input from the federal, state, and local governments.

The Transgender community is the most targeted group in the LGBTQ+ community. Trans people of color are even more likely to be targeted, with an overwhelming majority of deaths due to anti-trans violence in the United States being from the black community. In 2023, anti-trans hate crime in the UK rose by a profoundly concerning 56% compared to the previous year. As illustrated in the map below, nearly all parts of the UK have seen an extraordinary rise in anti-trans hate crime since 2011/2013. FBI figures reveal a 32.9% increase in anti-trans hate crime between 2021 and 2022. On the map below, you can see the increase in anti-trans hate crimes over time in the UK. If you click a specific police force area, it will show you the totals in 2011/13 and 2023.

This hatred is partly familiar and consistent with past generations – remember the way ‘transsexuals’ were treated and stigmatized in the 70s and 80s?

Yet this generation of hate is something different – more organized, more widespread, and more virulent. On both sides of the Atlantic, anti-trans hatred has spread deep roots in society – acting almost as a uniting factor between right-wing politics, conservative Christian groups, and conservative legislators. Over time, the anti-trans movement – and it truly is a movement – has become more radicalized and more extreme. Promoted by right-wing populists and influential figures in the US, misinformation about transgender people (and gender-affirming care) has created a moral panic that is increasingly dangerous. Misinformation about care offered at Boston Children’s Hospital led to death threats and bomb threats. The LGBTQ ‘groomer’ conspiracy has been promoted by major right-wing influences, including former President Trump, spreading the idea that trans people are pedophiles and groomers. Meanwhile, anti-trans bills restricting the rights of trans people, families, and children have been filed in most states, and many have been passed. Misinformation about trans people – particularly about gender-affirming care for children – has powered much of these efforts. Certain topics are used as dog-whistles to further recruit more members to the movement, largely seemingly ‘reasonable’ topics like whether trans people should play sports, what is a man and what is a woman, and whether trans people should be able to access bathrooms.

Yet the acceleration and radicalization have taken the toxic debate to an extremely dangerous place. Some politicians call for the forced detransition of all trans people, and others call, effectively, for the creation of concentration camps, and questioning the very right to existence of transgender people. Others push conversion therapy, bans on drag story hours, and book bans They espouse these views to millions of followers, further radicalizing the movement. In the UK, this is led by trans-erasing radical feminists, framing their views as being ‘gender-critical’. The ‘gender-critical’ movement in the UK was born out of a decision to review the Gender Recognition Act in 2012, which led to the formation of opposition groups focused on women’s rights. In 2020, the reform plan was dropped by the then-Prime Minister Boris Johnson. The LGB alliance (notice the dropped T) is one such prominent group. Gender Critical figures such as JK Rowling and Graham Linehan have espoused problematic views about trans people to millions of followers. In the UK, such views have become mainstream and are held by many in the media and government. The difficulty of accessing trans healthcare in the UK, coupled with the hostile environment, has given it the nickname ‘Terf Island’ in the trans community. In both countries, there is a concept that there is an ‘evil trans ideology’ sweeping the nation.

Finally, social media is a brutal place for a trans person. Even just being a trans person on Twitter often provokes immense hatred, including death threats, transphobia, and ‘jokes’ about trans suicide. Social media providers do not take action. There is a logical end to this movement, and as trans people we have seen it extensively. People ultimately say that trans people do not exist: perhaps they are just mentally ill, or perhaps they just shouldn’t exist anyway. Yet they also regularly argue for trans elimination and extinction from society.

I am a scholar of human rights abuses, war crimes, and mass atrocities. Yet when members of my community describe the situation as ‘trans genocide’, I find it increasingly hard to disagree.

One of the greatest impediments to the mental health of trans people is the inability to access treatment. When I was a trans teen, I was desperate to receive gender-affirming care – I wanted puberty blockers so that I didn’t experience male puberty, and I wanted to later have hormones. Yet I never tried, for the UK’s transgender care provision was so inadequate that the wait times were inconceivable. I did not seek care because I knew the official wait time would kill me, waiting for treatment that would never come. For context, the wait time for an initial appointment in the South-West was (and still is) 7 years. The NHS target is 18 weeks. It is unconscionable, and it kills people. I am extraordinarily lucky to have emigrated and to be receiving gender-affirming care here in Massachusetts.

The following statistics should shock you.

81% of trans adults have thought about suicide.

42% of trans adults have attempted suicide.

More than 50% of Transgender/Nonbinary Youth considered suicide in 2022.

In Denmark, trans people are more than 8 times more likely to attempt suicide than the general population.

My mind fell over a waterfall in February. For weeks, I had wanted to die, and my mental health continued to deteriorate. I became obsessed with suicide, and I set plans in motion to make it a reality. On the night I intended to end my life, I somehow (reluctantly) dragged myself into an Uber that took me to the ER at one of Boston’s biggest hospitals, and I plunged into the frigid, icy waters that were the unknowns of secure psychiatric care. At the ER, I was swiftly escorted by police officers and suited security guards, like a criminal, past the dozens of people awaiting treatment, before they guarded me in the psychiatric section. I was immediately stripped of my clothes and belongings before being given scrubs to wear, and I was quickly involuntarily sectioned by the ER’s psychiatrist and told I would be transferred to McLean Psychiatric Hospital in the morning. After a miserable night in the ER, I was escorted by security to a waiting ambulance despite being firmly strapped to a gurney. During the rough, jarring ambulance journey that transferred me to McLean, the lack of control and independence I had dawned on me. It was the worst journey of my life. The staff kept me alive when I did not want to be, but that involved extensive restrictions on basic rights - possessions, bedsheets, being observed even in the bathroom, and more. I was deeply unwell, and my trauma was too much to bear. It was hell, and my mind was hell too.

Between my few hours in the ER and my time at McLean, it would be a full 110 days before I would be discharged from secure psychiatric care. I was wheeled into McLean in the crisp February snow, and I would eventually walk out into the sweltering heat of June, missing all of spring. Including my subsequent Partial Hospitalization Program, I would ultimately spend 168 days in intensive psychiatric care. I needed every single day.

These times are so challenging that it is very difficult to imagine a future as a community, but I think it is vital that we do so. It will not be like this forever. The map below is an interactive version of Erin Reed's classification of states that are safe and unsafe based on legislation and other elements. Trans people will always exist and have always existed in the less safe states, and we should not forget them. Nonetheless, it provides a good visual guide to potentially safe places to move to.

Best Trans Cities

In imagining a future for the trans community, it is easy to think that we need to toil away to build our own transgender 'city on a hill' that offers protection, resources, and safety. Yet they already exist. In the map below, I have combined the Human Rights Campaign's 129 best cities for trans people with other weightings - mental health resources, the presence of shield laws, and transgender-youth-related bans. To be clear, every city featured in the map below is promising and could be an excellent choice for you and your family - there are no bad options. The map goes from pink to white, with bright pink being the most highly rated.

In this StoryMap, I have tried to show you the confluence of mental health and gender identity. We have explored the mental health crisis in the UK and the US, and we have uncovered the 'trans panic' as a crucial factor in the precarity of transgender mental health. To do so, I have presented several maps using authoritative data from around the world. I have also shared a little of my gender and mental health story, too - from childhood in England to adulthood in Boston, MA. If you are to take one thing away from this article, I want it to be that amidst the mental health crisis, the transgender community is hurting, is in danger, and needs your support. As the 2024 election cycle approaches, please consider asking your candidates to support trans people and protect trans rights - and if they won't, please consider asking them to not spread anti-trans hate and just leave us alone.

By the time you read this, I will have finished grad school and I will be figuring out what to do next. I hope that I will be considering gender-affirming surgery and that I will be continuing to invest time in my trans self - after all, I have so much to learn! As interesting a tale as my story makes, I am profoundly aware of the reality of how hard this year has been. It is hard to convey what those 110 days were like when I was kept alive by staff amidst oppressive restrictions. I still feel it so deeply. Above all else, I hope that I am mentally healthy and stable and that I continue to recover. In all honesty, getting through this semester and this year is a true miracle. In that, perhaps there is hope.

If you would like to read more of my work,  you can find me on Medium here . I write a lot about my gender transition and mental health recovery.

Thank you for reading! :)

If you would like more information or to support these causes, please consider supporting the organizations below:

The Human Rights Campaign supports the transgender community in court, in policy, and in education. It is does some of the most prominent and consequential transgender advocacy work.

The Trevor Project works at the intersection of mental health and LGBTQ+ youth, focusing on Suicide Prevention. It offers 24/7 crisis support over text, online chat, and by phone.

The National Alliance on Mental Illness (NAMI) is one of the most prominent mental-health-based organizations in the United States. It provides support including support groups and crisis support.

Wow! You defeated my storymap, and somehow made it to the end! You are, in my view, a hero. As a reward, I have delved deep into my trans/psych unit playlist (just for you!) to bring you three, deeply meaningful songs. 'Cameron' (Jillette Johnson) and 'Annabel' (Goldfrapp) are both beautiful, wistful songs about the trans experience - what it is, what you want it to be, and what it can be. 'This is what depression feels like' (Marina Lin) resonates with me as a deeply vulnerable, honest, earnest song about depression and mental health. It inspires me to try and translate my feelings into words better. It is hauntingly beautiful in its own way too, but its real beauty is in the depth of its lyrics.

If this StoryMap has made you feel unsafe at any point, please do not hesitate to call suicide and crisis lifelines in your country. In the US, adults can call the Suucide and Crisis Lifeline by dialling 988. Young people in the US can call, text, or message the Trevor Project's specialized crisis support for LGBTQ+ youth. In the UK, LGBTQ+ readers can contact the LGBT Switchboard support line on 0800 0119 100.