Considerations and Complexities of Accurate PTSD Assessment Among Transgender and Gender Diverse Adults

Posttraumatic stress disorder (PTSD) assessment among transgender and gender diverse (TGD) adults is complex because the literature offers little guidance on affirming assessment that accurately captures both trauma- and discrimination-related distress. This study aimed to characterize threats to precise PTSD assessment that arose during the Clinician-Administered PTSD Scale for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (CAPS-5). Our sample (N = 44) included trans women (38%), trans men (25%), nonbinary people (23%), and other TGD identities (14%). Participants were mostly White (75%), non-Latinx (82%), educated (91% at least some college), with a mean age of 37 years (SD = 15.5). Demographic and CAPS-5 scoring data as well as content analysis of audio-recorded CAPS-5 interviews are reported. All participants reported trauma exposure, and nearly half met PTSD diagnostic criteria (49%). Interpersonal assault was a common trauma type linked to posttraumatic symptoms (77%); 41% were sexual assaults; and 41% were discrimination-based (e.g., linked to gender identity) physical or sexual assaults. Qualitative findings suggest how and when discrimination-related experiences may threaten PTSD assessment accuracy, leading to overpathologizing or underdetection of symptoms, for example, (a) initial selection of a noncriterion A discrimination event as "worst event," (b) linking symptoms to internalized transphobia (rather than trauma), and (c) linking victimization to gender identity/expression. Threats to PTSD assessment were more common when symptoms were linked to discrimination-based traumatic events, suggesting the importance of understanding contextual factors of index events. We offer a framework for understanding unique challenges to the assessment of PTSD among TGD people and provide recommendations for improving assessment. Public Significance Statement We are the first to characterize the complexities of assessing posttraumatic stress disorder (PTSD) among transgender and gender diverse (TGD) adults, using the gold standard clinician interview assessment. All participants reported trauma exposure, with 48% meeting PTSD diagnostic criteria. Our study details how and when discrimination-related experiences may threaten PTSD assessment accuracy, leading to overpathologizing or underdetection of symptoms. We also provide recommendations for assessing PTSD in TGD adults.