particularly among older-generation white transgender women (Nuttbrock et al., 2009a). Transgender women who did not conform to gender roles in childhood tend to come out at an early age, either before or during early adulthood, and if so desired, change gender roles and feminize their body through hormone therapy and/or surgery (Bockting and Coleman, 2007; Lawrence, 2010). By contrast, transgender women who were gender role conforming in childhood tend to come out during mid- or later life (Bockting and Coleman, 2007; Lawrence, 2010), and their developmental challenges may vary as a result. Whereas gender role–nonconforming individuals must develop resilience in the face of enacted stigma early in life (Nuttbrock et al., 2010), gender role–conforming individuals may protect themselves against enacted stigma by keeping their transgender feelings private, yet are likely to experience felt stigma and, in isolation, may not benefit from the support a community of similar others can provide (Meyer, 2007).

Several authors have attempted to describe the process of transgender identity development or to adapt stage models of gay and lesbian coming out (Minton and McDonald, 1983) to the coming out process of transgender individuals. Bockting and Coleman (2007) describe five stages (pre-coming out, coming out, exploration, intimacy, and identity integration) based on Erikson’s (1950) model of social development and their extensive clinical experience in working with transgender individuals. Devor (2004) defines 14 possible stages of transgender identity development based on sociological field research and in-depth interviews with transgender men. Gagne and colleagues (1997) define four stages (early transgender experiences, coming out to one’s self, coming out to others, and resolution of identity) based on a qualitative study of transgender women. Lewins (1995) describes six stages of becoming a (transgender) woman (abiding anxiety, discovery, purging and delay, acceptance, surgical reassignment, and invisibility) based on interviews with transsexual women. Finally, based on her clinical experience and a review of the scientific literature, Lev (2004) describes six stages of transgender emergence: awareness; seeking information/reaching out; disclosure to significant others; exploration, identity, and self-labeling; exploration, transition issues, and possible body modification; and integration, acceptance, and posttransition issues. Although informed by formative research, these stage models have not been tested empirically and systematically.

MENTAL HEALTH STATUS

LGBT adults are typically well adjusted and mentally healthy. Studies based on probability samples of LGB populations indicate that the majority of LGB adults do not report mental health problems (Cochran and Mays,



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